Root cause analysis for hospital-acquired pressure injury.

Black JM. J Wound Ostomy Continence Nurs. 2019;46:298-304.

Pressure injuries are a persistent problem in health care. This article describes a three-level root cause analysis approach to determine physical, process, and systems factors that contribute to the occurrence of this never event. The author suggests that common cause analysis is an effective method to utilize root cause analysis results to determine latent weaknesses that facilitate pressure ulcer development.

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