Pressure Ulcers - Understanding what went wrong through RCA and PSIRF
This session will consider investigating pressure ulcer incidents within the context of Patient Safety Incident Response Framework (PSIRF) and the new National Wound Care Strategy Recommendations.
Undertaking investigations within your care home or home care team will help you understand what improvements need to be made, if any, to the care being delivered. Demonstrating that this activity is taking place, being acted upon and improving pressure ulcer incidents could support an improved CQC rating.
Learning Outcomes
- Understand briefly how a pressure ulcer is caused
- Be aware of the relevant national documents that guide when to investigate.
- Understand the key actions for prevention
- Understand how to determine which factors led to the development of a pressure ulcer
Meet our Experts

Heidi has been a Tissue Viability Nurse since 2002. Her interest and passion in the prevention and management of pressure ulcers began, however, in 1987 on registering as a nurse. She has worked in both acute and community care.
People who watched this also watched...
End of life care - what do I need to know?
Identifying when patients are in their last year of life can be challenging. The same can be said for recognising dying. This webinar explores what is available to help us help the people we care for to better plan for the end of their life, and when the time comes to die well. Attendees will learn about the myths associated with palliative and end of life care, and have the opportunity to ask questions towards the end of the session.
You Matter! exploring wellbeing for health and social care professionals
This webinar will focus on the value of personal and professional self-care, provide practical tips for techniques and strategies that can be used both in and out of work to promote good wellbeing and offer a safe setting for time for reflection.
Prescribing seating for cognitively impaired users: exploring the risks
When prescribing seating, our aim is to meet the needs of the service user by prescribing a chair that will provide the right level of support, enable safe, easier assisted or independent transfers, reduce risk of pressure injuries and enable them to obtain and maintain a good sitting posture in the provided chair. However when a service user has a cognitive impairment and has poor risk awareness, additional risks are present. In this session we aim to outline some of these possible additional risks and how to overcome them to ensure the service user and their carers/family remain as safe as possible when the service user is seated in a chair that is there to meet their needs.