In the fourth quarter of 2008, a young, morbidly obese patient in the intensive care unit (ICU) at Hunterdon Medical Center had a unit-acquired stage III pressure ulcer. The patient, who had been receiving mechanical ventilation for 32 days, had significant vasopressor requirements and a prolonged ICU stay. This pressure ulcer was our call to action. A multidisciplinary root cause analysis was conducted after the patient was discharged, and the following were identified as possible contributors to the development of the pressure ulcer:

  1. Morbid obesity contributing to sacral pressure and moisture trapping

  2. Significant vasopressor requirement for an extended period leading to decreased circulation to periphery

  3. Mechanical ventilation requiring that the head of the patient’s bed be elevated at least 30° to prevent ventilator-associated pneumonia also contributing to sacral pressure

  4. Braden scale score 12 (high risk for pressure ulcer)

  5. Fitted sheet and multiple pink...

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