Page 132 - H:\Annual Report\

• To complete and roll out the new electronic Root tubes which are reflective of national research showing
Cause Analysis tool for all medication errors that that most paediatric pressure ulcers are device related.
result in harm, which includes identification of harm,
contributory factors and financial implications. Alder Hey continues to have a strong focus on
education and training in the prevention, recognition
• Implement a new independent checking process
and treatment of pressure ulcers and clarifying and
across the trust.
simplifying reporting procedures.
• Reviewing Ulysses functionality to make it easier to
report an incident (e.g. more drop down functions). Whilst the reported figures in the table below reflect
an increase in numbers of pressure ulcers reported,
• Making staff more aware of the Yellow Card scheme.
We are planning an open day forum around Yellow these include all pressure ulcers, avoidable and
unavoidable. We have now introduced an improved
Card reporting.
system of defining when Grade 3 and 4 pressure ulcers
• Running a Medication Safety Week in June are avoidable and are taking specific steps to address
2018 during which we will run medication safety these through undertaking Root Cause Analysis and
workshops.
sharing lessons learned. The increase in numbers
is reflective of a greater awareness and improved
A.I.M.S education across the Trust which has led to increased
(Alder Hey Improving reporting. All of the Grade 3 pressure ulcers are linked
Medication Safety) to medical devices. Reducing the number of pressure
ulcers remains a high priority for the Trust and we
3.3.7 Reducing Harm from Pressure continue to take action through the Trust wide pressure
Ulcers - Sign Up To Safety Pledge ulcer action plan, for example we are seeking to identify
a means of safe cushioning of cannula devices to avoid
pressure ulcers.

Aim: No avoidable pressure ulcers.
Grade 2 Grade 3 Grade 4 Total
Targets: From the 2014/15 baseline:
2014/15 21 2 0 23
1. Reduce avoidable hospital acquired grade 2
pressure ulcers by 50%; this represents 10. 2015/16 23 1 1 25
2. Reduce avoidable hospital acquired grade 3 2016/17 27 7 0 34
pressure ulcers by 50%; this represents 1.
2017/18 32 6 0 38
3. Achieve zero avoidable hospital acquired grade 4
pressure ulcers.

Outcomes: Number of Reported Hospital Acquired
Pressure Ulcers
1. Increase of 11 grade 2 hospital acquired pressure
ulcers since 2014/15: this represents 32.
35
2. Increase of 4 hospital acquired grade 3 pressure
ulcers since 2014/15: this represents 6. 30
3. Achieved zero grade 4 hospital acquired pressure 25
ulcers.
20
4. Total number of pressure ulcers of grades 2-4 is
38 compared to 23 in 2014/15.
15
10
A pressure ulcer is an injury that breaks down the skin
and underlying tissue due to pressure, friction and 5
shear or a combination of these. They can be very
0
painful and debilitating and are often preventable. It is
Grade 2 Grade 3 Grade 4
recognised that immobilised and acutely ill neonates
and children are at risk of developing pressure ulcers,
2014/15 2016/17
particularly in a critical care environment. Most pressure
ulcers within our organisation are associated with 2015/16 2017/18
medical devices such as cannula and endo-tracheal

Alder Hey Children’s NHS Foundation Trust 132 Annual Report & Accounts 2017/18