Kaiser Permanente and the Alliance of Health Care Unions

Preventing Pressure Ulcers—Respiratory Team Preserves Patient Safety

This respiratory therapy team knew it was using breathing aids on patients longer term than it used to in the past. What care givers didn’t realize was that this was causing more pressure ulcers. So when they saw the data, they sprung into action. As one therapist put it, “We’re here to do something good and something positive,” not to cause harm. Using the structure of its unit-based team and partnership principles, the team came together to reduce the number of pressure ulcers.                                                                                                                 

Here's What Worked

  • Researching and trying different breathing equipment
  • Improving communication among team members and other health care workers, such as wound nurses
  • Focusing on fixing problems, not blaming each other

What can your team do to increase awareness of how equipment can impact patient care? 

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