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Running Head: Clinical Governance 1 Clinical Governance A 82 year old client named X with history of diabetes had been admitted to a hospital. She had her total hip replacement surgery. She has been immobile for a month and has developed a pressure ulcer .This essay uses a case example of pressure ulcer based on evidence exploring how a patient’s safety has been compromised and identifying the safety related quality issue and its root causes by using FISHBONE analysis. Furthermore, the essay will be providing QI initiatives and strategies to implement for the issue in the Australian health care system. Pressure ulcers are also known as bedsores as well as “decubitus ulcers” which are considered as injuries to skin as well as underlying tissue that results due to prolonged pressure posed on the skin. It mostly develops on the skins which aids in covering up the bony areas of the body (Koyangi et al. 2021). With widespread prevalence and incidence in all health settings, affecting approximately 1 in 7 hospital and 1 in 20 community patients, pressure ulcer (PUs) are a major burden to patients, carers, and healthcare systems. (Rutherford et al., 2018).According to Tschannen, D., & Anderson, C. (2020) pressure injuries continue to be a source of significant pain and delayed recovery for patients and substantial quality and cost issues for hospitals. Pressure ulcer prevalence has been recognised as a quality indicator for both patient safety and quality of care in hospital and community settings. (Hommel et al., 2016). Pressure ulcers (PU) are a common type of chronic wound that can have a substantial impact on health-related quality of life and patient outcomes. According to Blackburn, J., & Karen, O. (2018). Pressure ulcers have a negative influence on a number of patient outcomes, including physical, emotional and social dimensions of life. (Monaco et al., 2020). Patients are recognised to be mostly prone to bedsores who intend to suffer from graving medical conditions which in turn limits their ability of changing positions (Kasai, Isayama, & Sekido, 2021). The development of pressure ulcers or injuries can interfere with the patient's functional recovery, may be complicated by pain and infection, and can contribute to longer hospital stays (Niemeic et al. 2021). Pressure ulcers can diminish global life quality, contribute to rapid mortality in some patients and pose a significant cost to healthcare organizations. Blackburn, J., & Karen, O. (2018). The average daily cost by pressure injury stage was AU$26.42 for a Stage 1 pressure injury, AU$37.17 for a Stage 2 pressure injury, AU$30.01 for a Stage 3 pressure injury, and AU$10.22 for an Unstageable pressure injury. The projected cost of treatment was AU$104,510.41. At 42 days this cost extended to AU$116,552.79. This study has quantified the cost of pressure injury treatment in a residential aged care setting. (Wilson et al., 2018). The presence of pressure ulcers is a marker of poor overall prognosis and may contribute to premature mortality in some patients. People:The shortage of the staff members is accounted as the key weakness as it creates less time to perform any task.(Jeong, 2021). Understaffing, high staff turnover and limited staff knowledge are the barriers often reported for the limited adherence to pressure ulcer prevention guidelines that leads to frequent changing of staff resulting in inappropriate care. Pressure wound dressing conducted by a staff makes the wound worsen. Staffs are unaware about changes in guidelines relating pressure ulcer. Insufficient in services and knowledge. (Lavallée et al., 2018).Two hourly repositioning is also lacking due to shortage of staff. Policies: Nurses fail to accomplish “Braden Scale and IPOC” and Waterlow scale in each as well as every shift. Nurses fail to ensure initiation of charts that monitor pressure ulcers in terms of prevention intervention within the patients who are at high risk. Lack of risk assessment. Computerised charting system that makes it harder for noncompliant staffs.(Lavallée et al., 2018).The guidelines are complex to follow relating the situation. Nutritional diets haven’t been provided for the healing of pressure ulcer. Procedures:In terms of procedures, it can be identified that education and training to the nurse is considered as a significant aspect. However, due to lack of proper training on the basis of pressure ulcers is lacking that helps in creating, managing as well as conducting regulatory compliance training for the staff members. (Saghaleini et al. 2018). Incontinence can lead to pressure injury , Regular skin care is not being carried out to manage sweat and clean soiled or wet skin which could lead to further injury. (Lavallée et al., 2018). . Place : According to Guest et al. (2018),Limited budget in terms of money as well as finance has been considered as one of the significant challenge that has been faced by the health system as well as the patients primarily dealing with Pressure Ulcers. Lack of proper matresses,cushions,pillows,dressing materials play a vital role in prevention of pressure ulcer which is lacking in this case .Extrinsic factors relate to physical and environmental factors and can include shear, friction, and moisture. Presence of wrinkle in bed or linen that might cause pressure ulcers(Engels et al., 2016). Australian government has initiated the key strategy of a pressure ulcer is the usage of a pressure mattress. New nurses ensure orientation on the prevention of pressure ulcers through the help of different strategies. Moreover, repositioning of a patient is considered as a standard of care in terms of prevention in pressure ulcers (Gould et al. 2018). It also acts as a primary intervention approach which helps in the formulation of acute care settings among the patients. It is recommended to the health care systems to ensure comprehensive documentation which is imperative for determining safety of the patients (Silva et al. 2017). Leadership, education, ongoing quality improvement, clinical practice and policies to recognise unit level professional champions in PU prevention were factors that was part of a Factors Facilitating Pressure Ulcer Prevention Model The continuing prioritisation of these factors supports PU prevention and promote a redefinition of healthcare institutions to develop the culture organisation, educational programmes and, consequently to improve patients’ healthcare outcomes. (Gaspar et al., 2021). On the other hand, teamwork was indicated as a component that could effectively prevent PUs and improve patient safety. Also, having a clinical support specialist on tissue viability/wound care was pointed as an extra support in clinical practice for those nurses with less experience in this field. (Gaspar et al., 2021). A comprehensive assessment of patients' pressure areas informs the development of management and treatment plans to ensure appropriate monitoring and ongoing care. Patients' hydration and nutritional status should be assessed; a recognised tool should be used, such as the Malnutrition Universal Screening Tool (MUST). Correct completion of this tool guides interventions such as accessibility to food and fluids, dietary advice (how to follow a balanced diet with energy, protein and micronutrient requirements), dietitian referral and further interventions such as supplement drinks or tube feeding. Regular skin inspection should be carried out and a full reassessment completed if there has been a change in clinical status, mobility or underlying conditions (NICE, 2017). Patients who are identified as at risk of Pressure Ulcer development need repositioning frequently repositioning at least every 6 hours and every 4 hours for those at high risk. Where possible, patients should be encouraged to do this themselves. Patients on non-pressure-redistributing equipment should be repositioned more frequently. (NICE, 2017). Management of moisture is thought to be another important factor contributing to the prevention of PI. Supplies should be made available at the bedside of each at-risk patient who is incontinent, in order to help the staff to immediately clean, dry and protect the patient’s skin after each episode of incontinence. (Gupta et al., 2020). Risk assessment using a structured, validated risk assessment tool is the initial step in PI prevention.Patients' charts were audited within 24 hours of admission. Data collected included patient characteristics, pressure injury risk assessment score and level, and preventative interventions prescribed. In the study hospital, the Waterlow18 risk assessment score (RAS), which includes a malnutrition screening tool (MST, with score ≥ 2 triggering dietician referral), is used to categorise PI risk level (not at risk; at risk; high risk; very high risk) with a Pressure Injury Management Plan chart to guide and record intervention prescription. High-risk and very high-risk patients would also receive heel elevation, increased mobility and repositioning interventions, and prophylactic sacral dressings. (Lovegrove et al., 2018). Conclusion From the following study, it can be presumed that pressure ulcers are significant in Australian Health Care. In the above essay, the impacts of pressure ulcer on client and healthcare and its root cause analysis has been discussed using Fishbone analysis. Similarly, the quality improvement strategies prevelant to Australian Health Care system has been discussed. Reference List Buh, A. W., Mahmoud, H., Chen, W., McInnes, M. D., & Fergusson, D. A. (2021). Protocol: Effects of implementing Pressure Ulcer Prevention Practice Guidelines (PUPPG) in the prevention of pressure ulcers among hospitalised elderly patients: a systematic review protocol. BMJ Open, 11(3). https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7959222/ Chae, J., Hong, K. Y., & Kim, J. (2021). A Pressure Ulcer Care System For Remote Medical Assistance: Residual U-Net with an Attention Model Based for Wound Area Segmentation. arXiv preprint arXiv:2101.09433.https://arxiv.org/abs/2101.09433 Jeong, H. S. (2021). Non-surgical treatment for pressure ulcer. Journal of Medical Association/Taehan Uisa Hyophoe Chi, 64(1). https://pdfs.semanticscholar.org/1bf3/5223642a8b1b59af57b3cca0337bd0e48126.pdf Kasai, T., Isayama, T., & Sekido, M. (2021). Squamous cell carcinoma arising from an ischial pressure ulcer initially suspected to be necrotizing soft tissue infection: A case report. Journal of Tissue Viability.https://www.sciencedirect.com/science/article/pii/S0965206X21000036 Koyanagi, H., Kitamura, A., Nakagami, G., Kashiwabara, K., Sanada, H., & Sugama, J. (2021). Local wound management factors related to biofilm reduction in the pressure ulcer: A prospective observational study. Journal of Nursing Science, 18(2), e12394. https://onlinelibrary.wiley.com/doi/abs/10.1111/jjns.12394 Niemiec, S.M., Louiselle, A.E., Liechty, K.W. and Zgheib, C., 2021. Role of microRNAs in Pressure Ulcer Immune Response, Pathogenesis, and Treatment. International Journal of Molecular Sciences, 22(1), p.64. https://www.mdpi.com/1422-0067/22/1/64 Taylor, C., Mulligan, K., & McGraw, C. (2021). Barriers and enablers to the implementation of evidence‐based practice in pressure ulcer prevention and management in an integrated community care setting: A qualitative study informed by the theoretical domains framework.