Absence of pressure ulcers is increasingly being used as an indicator of quality nursing care, based on the premise that pressure ulcers are preventable. This retrospective study examined the occurrence, presentation, and timing of pressure ulcer development in 150 patients undergoing cardiac surgery. Pressure ulcer incidents were recorded in groups of patients who underwent surgery with use of a standard foam OR bed mattress; use of a fluid, pressure-reducing OR bed mattress; or use of a fluid, pressuring-reducing mattress after a comprehensive educational program on pressure ulcer prevention was presented to RNs. Tcers decreased when the fluid, pressure-reducing OR bed mattresses were used in conjunction with the comprehensive RN education program.