Clinical Care

How a simple board could cause harm

RERs teach us that pressure injuries could come from unlikely sources.


During hospitalization our patients’ skin can become fragile. A recent RER helps shed light on best practices for skin integrity and show how responsible event reports can help us improve.

Early on a Tuesday morning, a patient we will call Mrs. Keen received a portable chest X-ray in her hospital room. Mrs. Keen was on a low-air-loss mattress and needed an additional support board to ensure the image could be clearly seen. The X-ray was taken, and the imaging plate was removed. Six hours later, it was discovered that Mrs. Keen was still lying on the secondary support board. Thankfully, she suffered no harm, but a valuable lesson was learned.

Asante’s Pressure Injury Prevention/Interventions, Guidelines and Documentation policy (400-PCS-NURS-0200) provides guidelines for maintaining skin integrity and minimizing the risks of pressure injuries. The policy focuses on key guidance in the following areas:

  • Pressure, friction and shear reduction
  • Repositioning and early mobility
  • Skin care and moisture management
  • Nutrition

Although the policy is focused on the daily care from CNAs, RNs and our wound care team, the prevention guidelines are for everyone. Any one of our care providers interacting with a patient plays a role in identifying risks to our patients’ skin. Please take a moment to review this policy. Thank you to the care team member who reported this incident. Your reporting matters!

Tags: Holly Nickerson, pressure injuries, RER, STAT
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