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:

In reviewing this patient’s case, it was clear that we had no control over certain factors: morbid obesity, the score of 12 on the Braden Scale, the mechanical ventilation, and the high vasopressor requirement. We could, however, control the amount and quality of the barriers between the patient and the therapeutic mattress. With this in mind, our certified wound care...

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