Quarterly Data Summary Issue 11: Learning from reporting - pressure ulcers

This learning from reporting section, taken from Quarterly Data Summary Issue 11, focuses on pressure ulcers.

The analysis considers 14,704 incidents occurring between 1 January 2007 and 31 December 2007 that were reported to the Reporting and Learning Service by 12 August 2008. Of these, a sample of 241 incidents was subject to more detailed analysis.

It considers:

• reporting rates by type of organisation;
• demographics of patients with pressure ulcers;
• the place where the pressure ulcer was acquired;
• the grade of pressure ulcer;
• management of pressure ulcers and contributing factors;
• the location of pressure ulcers; and 
• the quality of reporting and learning.

Examples of typical reports are given. It concludes that the detail and quality of most local reports of pressure ulcers needs to be improved to better inform national priorities for action. However, root cause analysis of pressure ulcer incidents can help to identify local priorities for action in the first instance.