Quality & Safety Refection Corner Pressure Injuries
An 85 year old female patient developed a stage 4 pressure injury during a recent three month admission at Ryde Hospital. The incident was notified in the ims+ incident management system and a specialised Pressure Injury Incident Investigation was undertaken. During the review it was found that the patient had risk factors for developing a pressure injury at the time of her admission. This was further complicated by the development of additional risks during the course of the inpatient admission including incontinence and reduced mobility. Documentation of both the pressure injury and the management plan were poor and led to complications in the patient’s care. The patient underwent surgical management of the resultant wound with a vac dressing placed post-surgery. The effect this treatment had on the patient was significant. The injury sustained by the patient had ongoing complications for her and, at the time of discharge, it was determined the wound may never full heal. This patient’s experience reminds all clinical staff of the importance of pressure area care from risk assessment to management, especially for long stay patients. To learn more pressure injuries from a patient’s perspective please view the CEC Excellent Patient Story resource available here. Patient’s Own Medication Each month we have at least 1-2 medication related incidents where patients or their family member administer the patient’s “own medication”. Please remember when admitting patients to the ward to advise the patient and their family they are not to take their own medication while in hospital as:
• The medical team may change medications while in hospital
• Nursing staff may have already administered the medication, and they could be at risk of overdosing • All medications taken need to be formally recorded. Patient’s own medication must not remain with the patient, with the exception of adrenaline/epinephrine autoinjectors. Patient’s own medications must be placed into the green patient’s own medication bags and stored securely in the clean utility rooms. If the patient or family is of a CALD background, please ensure this is communicated via an interpreter
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