title: Why do patients develop severe pressure ulcers? A retrospective case study.
abstract: OBJECTIVE
  This study focuses on the ways in which the organisational context can influence the development of severe pressure ulcers. Severe pressure ulcers are important indicators of failures in the organisation and delivery of treatment and care. We have a good understanding of patients' risk factors, but a poor understanding of the role played by the organisational context in their development.
  
  
  METHODS
  The study was undertaken in six sites in Yorkshire, England. The settings were sampled in order to maximise diversity, and included patients' own homes, acute hospital medical and surgical wards, a community hospital and a nursing home during a period of respite care.
  
  
  METHODS
  Data were collected about eight individuals who developed severe pressure ulcers, using a retrospective case study design. The data sources included interviews with individuals with severe pressure ulcers, and with staff who had treated and cared for them, and clinical notes.
  
  
  RESULTS
  4 accounts indicated that specific actions by clinicians contributed to the development of severe pressure ulcers. Seven of the 8 accounts indicated that they developed in organisational contexts where (1) clinicians failed to listen and respond to the patients' or carers' observations about their risks or the quality of their treatment and care, (2) clinicians failed to recognise and respond to clear signs that a patient had a pressure ulcer or was at risk of developing one and (3) services were not effectively coordinated.
  
  
  CONCLUSIONS
  Patient accounts could only be partially explained in terms of specific events or sequences of events. The findings support the conclusion that there was general acceptance of suboptimal clinical practices in 7 of the 8 contexts where patients developed severe pressure ulcers.
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
authors.forename: Lisa
authors.initials: L
authors.lastname: Pinkney
authors.forename: Jane
authors.initials: J
authors.lastname: Nixon
authors.forename: Lyn
authors.initials: L
authors.lastname: Wilson
authors.forename: Susanne
authors.initials: S
authors.lastname: Coleman
authors.forename: Elizabeth
authors.initials: E
authors.lastname: McGinnis
authors.forename: Nikki
authors.initials: N
authors.lastname: Stubbs
authors.forename: Carol
authors.initials: C
authors.lastname: Dealey
authors.forename: Andrea
authors.initials: A
authors.lastname: Nelson
authors.forename: Malcolm
authors.initials: M
authors.lastname: Patterson
authors.forename: Justin
authors.initials: J
authors.lastname: Keen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019090:Case Management / Q000458:organization & administration / Q000592:standards; D016022:Case-Control Studies; D002983:Clinical Competence / Q000592:standards; D004739:England; D005260:Female; D006801:Humans; D008297:Male; D010819:Physician's Role; D010817:Physician-Patient Relations; D003668:Pressure Ulcer / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control / Q000523:psychology; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index