Perioperative pressure injury prevention: National Pressure Injury Advisory Panel root cause analysis toolkit 3.0

Ann Tescher, Michelle Deppisch, Cassendra Munro, Vince Jorgensen, Janet Cuddigan

Research output: Contribution to journalArticlepeer-review


OBJECTIVES: Operating room-related pressure injuries (ORPI) are particularly challenging to examine for several reasons. Time in the OR is often a distinct event within the hospitalisation, and discovery of an ORPI may occur between several hours and up to 5 days postoperatively. The National Pressure Injury Advisory Panel (NPIAP) first developed a root cause analysis (RCA) toolkit in 2017 as a systematic strategy for investigating the root causes of facility-acquired pressure injury (PI). The purpose of this 2021 RCA toolkit update was to address an expanded investigation of medical device-related PIs (MDRPIs), both inside and outside the OR, as well as the specific PI prevention issues of the perioperative area. METHODS: Clinicians have been using the 2017 toolkit as a basis for ongoing quality improvement tracking, since it provides more accurate information than data extractions from patient health records. A small working group consisting of NPIAP board and panel members developed investigative questions to identify the ORPI root causes and compliance with best practices for the entire perioperative experience. RESULTS: Action items are linked to evidence-based recommendations from the NPIAP/European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Injury Alliance 2019 International Guideline and the Association of PeriOperative Registered Nurses (AORN) Guidelines for Perioperative Practice. A multidisciplinary clinician guide was also developed to identify practice gaps and to compile the information into an action plan for staff education and/or process improvement. CONCLUSION: The updated NPIAP RCA toolkit provides mechanisms for investigating, compiling and trending data as a basis for data-driven quality improvement. Using the enhanced investigative tools, the root causes of both MDRPIs and ORPIs can be better understood to target efforts to reduce their occurrence.

Original languageEnglish (US)
Pages (from-to)S4-S9
JournalJournal of Wound Care
StatePublished - Dec 1 2022


  • medical device
  • perioperative
  • pressure injury
  • pressure ulcer
  • root cause analysis
  • wound
  • wound care
  • wound dressing
  • wound healing

ASJC Scopus subject areas

  • Fundamentals and skills
  • Nursing (miscellaneous)


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