Authors: (including presenting author): :
CHEUNG TP(1), SO KF(1), NG CF(1), LO KP(1), TSANG LF(1), LEUNG LM(1)
Affiliation: :
Nursing Services Division, United Christian Hospital
Keyword 1: :
Pressure Injury Prevention Strategies
Introduction: :
Pressure injuries (PI) remain a significant patient safety concern in acute care hospitals, often leading to prolonged hospital stays, increased costs, and reduced quality of life. Despite the implementation of standard prevention protocols and surface-level reviews, PI rates in the local hospital remained stagnant. This highlighted a critical gap: conventional monitoring and first-tier analysis were insufficient to uncover complex, multifactorial root causes. Persistent cases suggested that deeper systemic issues—such as variability in risk assessment, inconsistent compliance with preventive measures, and hidden contributory factors—were not being adequately addressed. To bridge this gap, a second-tier analysis was initiated within the PDCA cycle to provide a more comprehensive evaluation and identify the roots causes with areas for reinforcement.
Objectives: :
This aimed to strengthen pressure injury prevention strategies by integrating second-tier analysis into the PDCA cycle, enabling the identification and mitigation of unavoidable or recurrent incidents.
Methodology: :
Following initial PDCA implementation, a second-tier analysis was introduced to evaluate persistent or recurrent cases of PI. This deeper level of review involved 3 dimensions of analysis: 1) stratification of risk factors and assessment, 2) compliance and effectiveness of preventive intervention and 3) identification of contributing factors. Data were collected from hospital units, focusing on patient profile, assessment performed, preventive measures provided and other possible contributing factors to facilitate the analysis. The data were shared at hospital Nursing Services Meeting and Wound Care Consultative Committee meeting. Pre-and-post PI rate before and after launch of second-tier analysis was compared.
Result & Outcome: :
Since October 2025, the integration of second-tier analysis within the PDCA cycle enhanced root cause identification and corrective action planning. Outcomes included a measurable reduction in hospital-acquired PI, improved adherence to repositioning and skin assessment protocols, and strengthened staff accountability. After the implementation of second tier analysis, hospital acquired PI rate was recorded a reduction of 23-44%, from 1.14 to 0.64 and 0.88 in 2 consecutive months. Continuous refinement of interventions will be achieved through iterative PDCA cycles supported by deeper analysis. Embedding second-tier analysis into the PDCA cycle provides hospitals with a robust mechanism for pressure injury prevention. By enabling deeper exploration of underlying causes and reinforcing multidisciplinary collaboration, this approach supports continuous quality improvement and advances patient safety.
