Nearly all organizations concerned with healthcare quality have recognized pressure ulcers as a quality indicator. This assumption has impacted reimbursement policy and facility ratings, and resulted a risk-management burden for caregivers across the healthcare continuum. Despite the fact that pressure ulcers can sometimes reflect upon quality of care, it is increasingly recognized that many pressure ulcers are unavoidable. A new analysis of data collected by the Office of the Inspector General (OIG) and published in Advances in Skin and Wound Care shows that up to 40% of pressure ulcers are unavoidable. This data continues to shed doubt upon the utility of pressure ulcers as a quality indicator.

Jeff Levine, Jeffrey Levine MD geriatrician physician artist photographerOver the past 4 years the OIG released two studies on adverse events among Medicare beneficiaries in hospitals and skilled nursing facilities. A goal of these studies was to determine the cost of preventable adverse events to the Medicare program. These studies identified adverse events, determined harm levels of the events, developed and utilized methods to determine preventability, and measured their cost. The hospital study focused on 780 Medicare beneficiaries randomly selected from 999,645 discharges during October 2008, while the SNF population included 655 beneficiaries randomly selected from 100,771 patients whose stay began within 1 day of hospital discharge, had length-of-stay 35 days or less, and whose stay ended in August 2011.

A two phase review was employed to identify adverse events for both hospital and nursing home, with different criteria for each group. Adverse events included bleeding at surgical sites, medication related hypoglycemia, volume overload, delays in surgery, catheter related sepsis, surgical site infections, pressure ulcers, and many others. The hospital study initially screened for adverse events as follows: 1) certified medical coders identified codes in Medicare claims data that were not present on admission (POA); 2) nurse reviewers found potential adverse event; or 3) patient had hospital readmission within 30 days of discharge. 420 cases were flagged for the second phase, where the chart was reviewed by a group of physicians.

For the nursing home study, one nurse practitioner and four nurses performed the initial screen, reviewing the record for evidence of harm using an OIG-developed trigger tool to standardize reviews. This was followed by a second review by five contracted physicians of the 262 beneficiaries flagged in the initial screen. The physicians included a cardiologist, infectious disease specialist, internist, orthopedist, and geriatrician with experience as an SNF medical director.

Determination of preventability used a structured Decision Algorithm that was developed by the OIG for the study of adverse events in hospitals. Preventability was determined by identification of errors and system failures, whether the outcome was an anticipated event, and whether appropriate precautions were taken. The Decision Algorithm incorporated a two part process including a flow chart and a rationale list to evaluate and determine the final response. Reviewers judged preventability on the basis of information in the medical records, clinical experience with similar cases, research literature, and group discussion.

Preventability was indicated on a five-point response scale:

  • Clearly Preventable – Harm could definitely have been avoided through improved assessment or alternative actions.
  • Likely Preventable – Harm could have been avoided through improved assessment or alternative actions.
  • Likely Not Preventable – Harm could not have been avoided given the complexity of the resident’s condition or the care required.
  • Clearly Not Preventable – Harm could definitely not have been avoided given the complexity of the resident’s condition or the care required.
  • Unable to Determine – Unable to determine preventability because of incomplete documentation or case complexity.

The pressure ulcer data was published within each of the OIG studies and contained information on site, stage, and avoidability, but was not analyzed separately. With the assistance of Karen Zulkowski DNS, RN, a specialist in the field of pressure ulcers and wound care, we analyzed the pressure ulcer data in the OIG studies. In both hospitals and nursing homes, roughly 40% of pressure ulcers were found unavoidable. We are unaware of studies that provide comparable preventability rates, nonetheless the high rate of unavoidable ulcers leads to doubts on the reliability of pressure ulcers as a quality indicator – even with the flaws in the study design that are discussed in my publication. These doubts are particularly acute in light of increasing recognition that some pressure ulcers occur even with the best of care.  

As I discussed in an earlier blog post, the term “never event” is commonly applied to pressure ulcers, giving the impression that they are always associated with medical error. As such, it lends this outcome an emotional charge that can lead to misplaced patient dissatisfaction and unwarranted accusations of wrongdoing or poor quality. Although pressure ulcers are sometimes associated with factors such as inadequate staffing and nutritional care, the preventability of all pressure ulcers has never been proven, and most caregivers agree that they can occur even in the best of circumstances. As such, we need to take pause when considering pressure ulcers as a quality indicator.

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The article discussed here is referenced as follows and can be accessed HERE:

Levine, Jeffrey M. MD, AGSF, CWSP; Zulkowski, Karen M. DNS, RN.  Secondary Analysis of Office of Inspector General’s Pressure Ulcer Data: Incidence, Avoidability, and Level of Harm.  Advances in Skin & Wound Care:  September 2015 – Volume 28 – Issue 9 – p 420–428. 

References for this post include:

Department of Health and Human Services, Office of Inspector General.   Adverse Events in Hospitals:  National Incidence Among Medicare Beneficiaries. November 2010, OEI-06-09-00090.

Department of Health and Human Services, Office of Inspector General.   Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.  February 2014.  Accessible at:

Related posts:

Pressure Ulcers as “Never Event”: Fact or Myth?
Historical Roots of the “Avoidable-Unavoidable” Pressure Ulcer Controversy
Determining the Avoidability of Pressure Ulcers
New Research Sheds Light on Hospital Acquired Pressure Ulcers
New Pocket Guide to Pressure Ulcers
CMS recognizes the Kennedy Terminal Ulcer in Long-term Care Hospitals
NPUAP Introduces New Clinical Practice Guideline for Pressure Ulcers
Jean Martin Charcot’s Lecture on Pressure Ulcers:  An Important Historical Document