As one of the nation's first and most trusted Patient Safety Organizations, we understand the importance of knowledge sharing in order to improve the quality of healthcare. For this reason, Clarity PSO publishes a series of educational reports--The Clarity PSO Learning Series--that focus on the risk-quality-safety (RQS) issues we have spotted through our incident reporting data collection and analyses. These reports include our findings on a given topic and our recommendations on how to use knowledge to mitigate risk and improve patient safety.
The latest report explores skin-related events, specifically pressure ulcers, focusing on new or existing pressure ulcers that advanced to stage III or stage IV, unstageable pressure ulcers, and most specifically, suspected deep-tissue injuries.