Date of Graduation

Summer 8-6-2025

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

MSN project

First Advisor

Dr. Ghada Dunbar, PhD, DNP, MHA, RN, NEA-BC, NPD-BC, CENP, CNML

Abstract

Hospital-acquired pressure injuries (HAPIs) can significantly impact a patient’s quality of care, increase organizational costs, and pose significant risks for patient safety. According to the United Hospital Fund, “Hospital-acquired pressure injuries (HAPIs)—also known as pressure ulcers or bed sores—can pose significant problems for both the patient and hospital. Being an injury to the skin or underlying tissue, HAPIs can be painful, cause infections, hinder recovery, and prolong a patient’s time in the hospital” (United Hospital Fund, 2025). This quality improvement (QI) project took place in a small, urban southern California hospital with a high incidence and prevalence rate of HAPIs (compared to the national benchmark) in a medical-surgical unit. After an initial discussion with the organization’s only wound care nurse coordinator (WCC), the team discovered interventions they have attempted to implement within the units, such as a leaf-turning system, four-eye skin assessments, skin champions, and mandatory educational sessions on ways to prevent pressure injuries- all of which have been successful according to evidence-based practice. Despite attempts at evidence-based implementation, the unit continued to experience high rates of pressure injuries, attributed to various contributing factors. In collaboration with the WCC for our primary intervention, we developed a visual reference guide that contains current supplies on the unit and example photos of the stages of pressure injuries. The current reference guide on this unit was found to be outdated and difficult to access for unit staff. Therefore, creating an updated visual reference guide was our main focus for the intervention. Evaluation of data will be carried out by the following cohort, using quarterly incidence and prevalence studies of pressure injuries acquired within the unit. Once the updated visual guide is implemented, the team hopes to see a 1% monthly decrease in the incidence and prevalence of HAPIs. The goal is to provide the staff with an easily accessible resource that they can utilize when treating and staging pressure injuries.

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