Practice of Medicine


Reducing the Risks of Hospital-Acquired Pressure Ulcers

Download the full report

Hospital acquired pressure ulcers account for 6% of medical malpractice claims in hospitals and healthcare facilities insured by MagMutual and affect 2.5 million patients per year in the United States. The prevention of pressure ulcers plays a major role in reducing the incidence of other illnesses and improving the quality of life for patients.

To help reduce the occurrence of pressure ulcers in hospitals and healthcare facilities, MagMutual’s medical faculty and risk consultants have analyzed our claims data, determined the main causes of claims related to these injuries and developed strategies to improve patient outcomes. 

Top Risks

The main causes of claims related to hospital-acquired pressure ulcers are:

  • Failure to Place on the Correct Support Surface Offloading Device and/or Cushion
  • Failure to Address Nutrition
  • Failure to Properly Turn
  • Documentation: Omission (no note about pressure relieving devices and increasing the frequency of turning and repositioning) 

            Top Strategies for Reduction

            Based on these top risk drivers, implementing the following clinical and operational strategies can help you prevent unexpected outcomes and increase defensibility of a medical malpractice claim:

            Clinical strategies

            • Reposition at a minimum of every 2 hours using turn assists. Float heels. Keep HOB <30 degrees, if possible. Remove bedpans immediately after use. Use dynamic surfaces for pressure reduction: alternating air overlay, low air loss bed and air-fluidized beds in high-risk patients.
            • Ensure that a comprehensive skin assessment is performed within 24 hours of admission. Determine whether this assessment is being performed. Implement a pressure ulcer prevention policy. Perform Braden Score and head-to-toe skin assessment every 12 hours.
            • Individual care plan for nutritional needs. Ideal if nutrition referral is an automated process. 

            Operational strategies

            • Train, audit and continually educate about full skin assessments. Utilize pressure-relieving devices (pads under all bony prominences and medical devices) and skin care products (moisture barrier creams and absorbent pads); document when used. Establish a nursing committee with staff nurses and CNAs to review policies, analyze pressure injury data and identify trends.
            • Consider identifying one unit where the pressure ulcer problem is the most severe for targeted changes. Find champions within the best-performing units where staff are most enthusiastic about pressure ulcer reduction. Determine which practices need changing and how best practices will be operationalized. Document use of malnutrition screening tools. Document percent eaten with every meal.

                Other Top Risks

                Though pressure ulcers account for a significant number of claims that occur in hospitals and healthcare facilities according to our data, we’ve identified several other drivers of loss based on claims frequency:

                Risk Drivers by Top Cause
                Key Loss DriverTop Clinical Loss CauseTop Non-Clinical Contributing Factor% of Claims
                (A) Hospital fallTreatmentFailure to follow protocol17%
                (B) Medication errorTreatmentDocumentation9%
                (C) Hospital aquired pressure ulcerTreatmentDocumentation6%
                (D) Colonoscopy complicationTreatmentDocumentation5%
                (E) Failure/delay in performance of C-sectionTreatmentCommunication3%
                (F) Failure/delay in diagnosis of sepsisTreatmentCommunication2%
                Risk Drivers by Frequency


                Download the full report with indemnity payment information and strategies for all the key loss drivers to help you reduce risk in the top areas that claims occur.

                MagMutual PolicyOwners: Log in to view the full report

                Not a policyholder? Download Here

                Data Collection & Methodology

                Data is based on MagMutual closed claims from 2011-2021 and corresponding exposure data. Clinical and non-clinical loss drivers are based on an in-depth review of each claim by a medical professional or clinical risk consultant. Risk reduction strategies are based on input from practicing physicians.


                Want to learn more?

                Interested in how MagMutual can help?

                View our products


                The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.