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National Patient Safety Agency

NHS to adopt zero tolerance approach to pressure ulcers

13 July 2010

Pressure ulcers can cause serious pain and severe harm to patients and cost the NHS billions of pounds each year to treat.  Yet in the majority of cases they can be prevented if simple measures were followed.


As part of its 10 for 2010 programme, * the National Patient Safety Agency (NPSA) is urging NHS organisations across England and Wales to work towards preventing all pressure ulcers.

The NPSA says the solutions are very simple; observing patients’ skin and changing the position of patients at regular intervals as well as checking for a moisture free environment and monitoring their nutritional status.  These small changes should make a big difference to reduce the chances of pressure ulcers from developing.


In addition, the NPSA will be conducting a number of briefings and workshops at NHS organisations, highlighting and urging staff to share best practice and to support local and national educational initiatives, such as Your Turn. **


Caroline Lecko, Patient Safety Lead for Nutrition and Pressure Ulcers, said: “This programme is all about adopting a zero tolerance approach to pressure ulcers across the NHS.


“We will be encouraging clinicians to work together and to share best practice techniques that have proven successful in other hospitals or clinical settings.

“We will also be using reported patient safety incidents to help us prioritise which particular areas we need to concentrate our effort.”


Since 2005, there have been around 75,000 patient safety incidents reported to the NPSA of patients developing pressure ulcers.

Analysis of the reported patient safety incidents has identified that pressure ulcers are not just associated with those typically considered at risk.


Ms Lecko added: “We have had around 100 patient safety incidents of women developing pressure ulcers in maternity wards having given birth, which is clearly concerning.

“Therefore, as part of the programme, we will be highlighting that pressure ulcer prevention must be a priority for healthcare staff across all areas of the NHS.” 


The pressure ulcers aspect of NPSA’s 10 for 2010 programme will be a focus for the national quality and productivity agenda which aims to reduce harm from pressure ulcers, catheter acquired urinary tract infection, falls and venous thromboembolism (VTE).


The NPSA will also be working to support NHS organisations and staff to further improve patient care in these clinical areas.


Notes to editors


A pressure ulcer, sometimes referred as pressure or bed sore, is an area of skin that breaks down and is typically caused by:


• Pressure – the weight of the body pressing down on the skin;
• Shear – when layers of skin are forced to slide – for example when you are pulled up a chair or bed;
• Friction – rubbing of the skin.


Pressure ulcers are said to affect up to 20 per cent of patients in acute care, 30 per cent of people in the community and 20 per cent of people in nursing and residential homes.  

The NHS spends up to four billion pounds treating pressure ulcers and related conditions each year and the costs of treating the most severe cases ranges from £11,000 to as much as £40,000 per person.


If left untreated or infected, pressure ulcers can lead to severe pain, serious harm or even death.


* 10 for 2010 programme - 10 for 2010 aims to significantly reduce levels of harm within the NHS.  It is about NHS organisations working together to reduce instances of harm to all patient who use NHS services.


The ten areas that comprise 10 for 2010 are high risk areas.  The NPSA has allocated clinical leads to work with NHS organisations across England and Wales to raise awareness and implement working practices.

By concentrating efforts on ten of the most high risk areas, we will make sure these initiatives are effectively implemented across NHS organisations in England and Wales.

Working in partnership with NHS organisations 10 for 2010 will use campaigns and leadership to drive change in ten key areas of clinical activity.
• Deterioration
• Reducing harm from Falls
• Insulin
• Anticoagulation
• Pressure Ulcers
• Five steps to Safer Surgery
• Reducing Avoidable Harm in Childbirth
• Suicide Prevention within the Health Community
• Matching Michigan
• Learning Disabilities


** Your Turn is a national charitable movement aimed at making the reporting of pressure sores in the UK mandatory – http://www.your-turn.org.uk

Media enquiries to the NPSA Press Office:

Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk

Dominic Stevenson – 020 7927 9351 / dominic.stevenson@npsa.nhs.uk


Out of hours – 0788 411 5956


The National Patient Safety Agency (NPSA) is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, Patient Safety and the National Clinical Assessment Service. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.nrls.npsa.nhs.uk.