Unavoidable pressure injuries and the changing view of “never events”: why it matters for quality measurement and the evaluation of care.
There is increasing recognition that some pressure injuries may develop despite appropriate medical and nursing care, particularly in older adults whose age-related changes in tissue integrity are compounded by severe systemic illness and physiological deterioration. This raises questions about the appropriateness of classifying pressure injuries as “never events” and their validity as indicators of healthcare quality. Recent changes in national patient safety reporting frameworks highlight the importance of distinguishing adverse clinical outcomes from deficiencies in care.
Never Events Re-Examined
The term “never event” emerged from the patient safety movement in the early 2000s. The National Quality Forum (NQF) developed a framework of serious, largely preventable incidents such as wrong-site surgery, retained surgical instruments, and certain medication and transfusion errors. Stages 3 and 4 hospital-acquired pressure ulcers were included, placing them among events considered preventable enough to warrant special reporting.
The Centers for Medicare & Medicaid Services (CMS) did not formally adopt the term “never event” when it implemented its payment policy in 2008. It used the designation “Hospital-Acquired Conditions” (HACs), which included advanced pressure ulcers. A HAC is a payment and surveillance category, not a determination that an error occurred.
This distinction matters. Wrong-site surgery is a discrete, identifiable error. A pressure injury is often a complication arising from multiple interacting factors.
Recent developments reflect growing recognition of these distinctions:
- NHS England (2024–2025). A 2024 consultation, with findings published in September 2025, questioned the effectiveness of the Never Events framework. Only 8% of respondents favored retaining the existing framework unchanged. Concerns included the potential for the terminology to promote blame rather than learning.
- NQF and The Joint Commission (January 2026). Updated Serious Reportable Event guidance narrows the reporting criteria for hospital-acquired pressure injuries to serious injuries that are largely preventable. The revisions recognize that clinical circumstances may restrict the implementation or effectiveness of preventive interventions. This represents a significant departure from the earlier approach, which included these injuries without the same explicit consideration of avoidability.
These developments challenge the assumption that a pressure injury automatically establishes inadequate care. Meaningful assessment requires attention to the patient’s underlying condition, the preventive interventions in place, and the clinical circumstances surrounding tissue breakdown.
Are Pressure Injuries Reliable Quality Indicators?
Pressure injury rates are widely used to measure quality in hospitals and long-term care facilities, and tracking them supports quality improvement. Still, a pressure injury does not necessarily indicate poor care.
Pressure injuries result from interactions among mechanical loading, tissue tolerance, perfusion, mobility, nutritional status, and underlying disease. In older adults with frailty, advanced illness, and multisystem decline, these factors can severely compromise tissue viability despite appropriate prevention.
This is not a new observation:
- Unavoidable pressure injury. A 2014 National Pressure Ulcer Advisory Panel (now NPIAP) consensus conference concluded that unavoidable pressure injuries do occur. It identified hemodynamic instability, limitations on repositioning, and other clinical conditions as factors contributing to unavoidability.
- Skin failure. The concept describes tissue breakdown associated with severe systemic deterioration, particularly in critically ill and dying patients. Its definition and diagnostic criteria remain under debate. Nevertheless, it highlights how impaired perfusion and systemic illness, together with mechanical loading, complicate retrospective judgments about preventability.
- Federal long-term care guidance. Federal nursing home regulations require that a resident not develop pressure ulcers “unless the individual’s clinical condition demonstrates that they were unavoidable” (42 CFR §483.25(b)(1)). CMS surveyor guidance at F-Tag 686 defines an unavoidable pressure injury as one that develops even though the facility evaluated the resident’s clinical condition and risk factors; implemented interventions consistent with the resident’s needs, goals, and professional standards of practice; monitored their impact; and revised the approach as appropriate. Under this framework, the occurrence of a pressure injury does not, by itself, establish a regulatory violation or deficient care.
Determining Whether Pressure Injuries Are Unavoidable
The “never event” label can create the impression that a pressure injury necessarily reflects inadequate care. That impression affects internal quality review, regulatory surveys, and medical-legal evaluations alike. In each setting, the injury itself may be treated as evidence of deficient care.
Whether a particular pressure injury was avoidable cannot be determined from the wound alone. Neither the presence nor the severity of a pressure injury, considered in isolation, establishes whether appropriate preventive care was provided. A fair evaluation considers the patient as a whole: underlying illness, physiological status, the trajectory of decline, and the patient’s own goals and preferences. It must also consider the care provided and whether it was consistent with accepted professional standards.
A More Meaningful Approach
Pressure injury prevention remains an essential responsibility of healthcare professionals. Yet even well-delivered prevention cannot guarantee that tissue breakdown will not occur, particularly in the sickest and most vulnerable patients.
The evolving perspective on never events recognizes that patient safety cannot be judged apart from clinical complexity and physiological vulnerability. Sound quality assessment examines both the care delivered and the circumstances in which an adverse outcome occurred.
The bottom line is that a pressure injury is not by itself proof of inadequate care.
About the Author
Jeffrey M. Levine, MD, AGSF, is Clinical Professor of Geriatric Medicine and Palliative Care at the Icahn School of Medicine at Mount Sinai. He has published extensively on pressure injuries, skin failure, chronic wounds, and wound care in older adults, and palliative care for chronic wounds.
References
NHS England. Never Events framework: 2024 consultation findings. Published September 16, 2025. NHS England.
The Joint Commission, National Quality Forum. Aligning Patient Safety Event Reporting: 2025 Updates to Sentinel Events and Serious Reportable Events. January 2026. Official report.
Edsberg LE, Langemo D, Baharestani MM, Posthauer ME, Goldberg M. Unavoidable pressure injury: state of the science and consensus outcomes. J Wound Ostomy Continence Nurs. 2014;41(4):313-334.
Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP: Guidance to Surveyors for Long Term Care Facilities. F686, Treatment/Services to Prevent/Heal Pressure Ulcers. CMS guidance.
Related posts:
Seeing Is Believing: What Our Eyes Teach Us About Pressure Injuries and Skin Failure
Skin Failure and Pressure Injuries: The Search for Clarity
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