Story: The Case of “Linda’s Pressure Injury”

(Name changed for privacy; drawn from a real, publicly reported patient safety case used in hospital safety trainings)

Background: Linda, a 72-year-old retired schoolteacher, was admitted to a large community hospital after elective abdominal surgery. She had several risk factors: diabetes, mild malnutrition, and limited mobility post-surgery.

Timeline of Events:

· Day 1–2: Nurses documented that Linda had a Braden score of 14 ( mild risk). The care plan included repositioning every 2 hours, but the unit was short-staffed. Turning was inconsistently done, and no pressure-relieving mattress was ordered.

· Day 3: A small red area was noted on her sacrum, but no wound care consult was placed. Documentation was incomplete, and the day shift assumed the night shift would follow up.

· Day 5: The redness turned into a blistered Stage 2 pressure injury. Linda began complaining of pain, but her pain was dismissed as “normal post-op discomfort.”

· Day 7: The wound deteriorated to a Stage 3 ulcer with drainage. Infection set in, requiring IV antibiotics and a longer hospital stay.

· Outcome: Linda was discharged after an additional 12 days with a complex wound requiring home health care. She described feeling ignored and helpless and later became an advocate for pressure injury prevention in hospitals.

· Part A – Questions (Answer All 5)

1. Risk Identification 🔎 Linda’s initial Braden score was 14. (0.5pts)

· What specific risk factors contributed to this score, and why should a score of 14 trigger preventive interventions?

· System Factors 🏥 Staffing shortages were noted during Linda’s hospitalization. (0.5pts)

· How should nurses and the healthcare team respond when short staffing threatens completion of essential safety measures (e.g., repositioning every 2 hours)?

2. Communication 💬 A red area was documented on Day 3 but not followed up. (0.5pts)

· Describe the correct communication and escalation steps a nurse should take when early skin changes are observed.

3. Patient-Centered Care ❤️ Linda reported pain that was dismissed as “normal post-op discomfort.” (0.5pts)

· How can nurses validate and advocate for a patient’s concerns to prevent harm?

4. Preventive Nursing Measures 🛏️ List at least three specific interventions that should have been implemented by Day 1–2 to prevent the pressure injury from progressing. (0.5pts)

Part B – Reflection (Short Paragraph) (2.5pts)

· 💡 Looking Forward Based on Linda’s experience, reflect on one key change you would personally make in your nursing practice (or on a unit) to prevent a similar incident.

· How will you help ensure every patient’s skin safety is protected, even during busy or understaffed shifts?

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