Pressure injuries the ‘scarlet letter’ of patient care

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  • Elizabeth Hiffmann says:

    My mother has a live in caretaker. She is very dedicated and treats my mother well. Also the agency she works for has a nurse who comes regularly. However, my mother has developed bed sores which required her to go to the hisi. Is this neglect or something that could have happened anyway

  • Linda Murphy says:

    Thanks to Karen et al for giving voice to my mother-in-law’s story and the more recent experience of my Mom. I hope our stories will alert others to the potential consequences.

    By chance, Dad was squirmy and complained of a sore ‘bum’ this week during my visit. I asked staff to move him into bed as he was really uncomfortable and to check the area while changing him. Unfortunately I had to leave for an appointment, but I followed up with an email to the director, care later that day to ask for him to be examined, to ask what schedule was used for repositioning Dad or moving him between wheel chair and bed. I also noted that an alarm pad had been positioned over his air cushion rendering it virtually useless.

    I learned today (from a staff nutritionist) that Dad has a stage 2 pressure wound. She called to ask if I agreed to him receiving Resource 2.0 protein booster to accelerate healing. We were both surprised that no o e had notified me.

    I like the suggestion from Elizabeth Rankin. I think a prevention and care checklist should be posted – in all rooms of patients with restricted mobility and in all bathing/shower areas.

  • Hina Laeeque says:

    Very well written and balanced article. This is the kind of healthy debate we need in healthcare! Thank you to Linda Murphy for sharing your story. The Canadian Patient Safety Institute with partners has listed Stave 3 and 4 pressure ulcers are listed as a never event. Read more here:

  • Jessica Hegg says:

    Great article! Pressure ulcers are far more common than people realize and it’s so important to know what risk factors to look for. Thanks for sharing this story

  • Elizabeth Rankin says:

    This is a story that never seems to have a happy ending. When I trained to become a nurse bedsores were considered the fault of poor nursing care. It was stressed while we bathed our patients (this doesn’t happen anymore) that we focus on the pressure points to see whether or not there was any indication of the skin being compromised in any way, particularly on those who were bedridden. We always massaged the skin in irritated areas as well as gave back rubs after we bathed the patient and as part of the routine for PM and HS care. This also doesn’t happen any more. We had to carefully document the process of skin care in the same way that medications are noted when they are given. What comes to mind here is the need for a carefully designed “checklist” of items that represent the issues related to bedsores that is completed and noted (dated and signed) at the change of each shift. I sometimes wonder how much “hands on” care nurses actually do anymore with the stories I hear that reflect this concern and many other issues.

    What might help alleviate this situation both within hospitals, long term care settings and in the community? If the family members ( or a close friend) are “trained” to understand how this can be avoided and learn how to assist their loved ones, it is possible to reduce the incidence of bedsores. It seems patients and families are having to take on more responsibility to make sure they “don’t become a victim of the health care system” but they are not adequately”trained” to focus on prevention or become the eyes and ears for the patient who is unable to do this for themselves.

    The fact that more money is spent to administer programs rather than hire appropriate staff to administer the care that is needed, we have a dilemma. Where are our priorities? Once we have this sorted out many of the issues in health care will work to the patient’s advantage and to the caring hands of those that serve patients.

    Elizabeth Rankin, BScN

    • MdM says:

      Excellent comment Elizabeth! In my experience, overall quality of health care is in steep decline, many seriously ill patients are also not being properly fed, or cleaned. PRN’s no longer provide basic hygienic fingernail or hair care, for example. There seems to be no time for personal care on hospital units, but I think it is a health policy problem more so than nurse training.

  • Cathie Hofstetter says:

    Great article! I was lucky in that my mother was in an excellent long term care facility for 7 years whose PSW’s were vigilant about skin care. When my mother fell and broke her hip and went into the hospital for surgery, the director of care at her home called and told me to talk to her nurses about their skin care protocol, which seemed to be non-existent. They then provided quilted booties and a sheep skin rug to put underneath her, but because they weren’t adequately addressing her pain post surgery, she was writhing around in the bed and the booties would be either off or half way up her leg. So I spoke to them about managing her pain more consistently, and then she settled and the booties proved helpful. Fortunately, she was released 4 days post surgery back to the excellent care of her LTC home, with no sign of a pressure sore. So ‘see something, say something’ is excellent advice!

  • Wendy Nicklin says:

    This is an excellent article and one deserving of wide circulation, informative to the public and health care providers! Everyone has a role and responsibility in reducing the rate of pressure ulcers. For a healthcare ‘complication’ that we have known about for many many years progress has been made yet we still have a long way to go and the risk will always be with us.


Karen Palmer


Karen is the Destination Development and Marketing Coordinator at The Corporation of the County of Prince Edward.

Maureen Taylor


Maureen Taylor is a Physician Assistant who worked as a medical journalist and television reporter for the CBC for two decades.

Joshua Tepper


Joshua Tepper is a family physician and the President and Chief Executive Officer of North York General Hospital. He is also a member of the Healthy Debate editorial board.

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