Hospital-acquired pressure injuries: Are they accurately reported? A prospective descriptive study in a large tertiary hospital in Australia

J Tissue Viability. 2018 Nov;27(4):203-210. doi: 10.1016/j.jtv.2018.07.003. Epub 2018 Jul 10.


Aim: The aim of this study was to (1) examine the reasons for the increased incidence of hospital-acquired pressure injuries (HAPIs) reported in the Incident Information Management System (IIMS), and (2) gain feedback from nurses regarding HAPI being reported in the IIMS at one tertiary hospital in Australia.

Materials and methods: This prospective descriptive study included a review of patients with a reported HAPI from July 2015 to June 2016. Patient assessment and semi-structured interviews with nurses were conducted. Interview data were anonymised and content thematically analysed.

Results: Data were collected on 417 patients who were reported to have a HAPI; of these, 363 patients were clinically assessed. 69.7% (253/363) were inaccurately reported in the IIMS, based on stage, location, not a true pressure injury or not hospital-acquired. A high number of patients (176/363, 48.5%) were found to have various skin conditions that were not HAPIs. Three themes were identified from the interviews: (1) meeting the mandated reporting requirements; (2) incident reporting and communication; (3) difficulties documenting aetiology.

Conclusion: This study identified inaccuracies in diagnosing, classifying and reporting pressure injuries. Nurses described barriers and challenges to classifying and reporting HAPIs. Inaccurate reporting can lead to incorrect conclusions especially when reported data alone is relied upon for patient treatment, benchmarking and analysis. Guidelines are needed at a national and international level to support the quality of clinical assessment, reporting and documentation. Findings from this study have led to a new approach to patient assessment and to minimise errors in incident reporting at this organisation.

Keywords: Hospital-acquired; Incident Information Management System; Incident reporting; Pressure injury; Pressure ulcer.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Australia / epidemiology
  • Female
  • Humans
  • Iatrogenic Disease / epidemiology*
  • Male
  • Middle Aged
  • Pressure Ulcer / epidemiology
  • Pressure Ulcer / etiology*
  • Prospective Studies
  • Risk Management / methods
  • Risk Management / standards*
  • Risk Management / statistics & numerical data
  • Tertiary Care Centers / organization & administration
  • Tertiary Care Centers / statistics & numerical data