Details
Rate of hospital-acquired pressure injuries (stages 3 and 4 and unstageable)
-
Patients within hospitals are at risk of developing pressure injuries. Cases of pressure injuries have risen steadily in Ontario, from about 1,245 per 100,000 hospitalizations in 2020/21 to about 1,920 per 100,000 hospitalizations in 2024/25. Advanced-stage (stages 3 and 4 and unstageable) and hospital-acquired pressure injuries are preventable and are identified as a hospital never event. Pressure injuries contribute to longer hospital stays and increased risks for significant patient harm (pain, infection, mortality) and to patient safety. Reducing hospital-acquired pressure injuries is a patient safety priority. Pressure injuries can be prevented through early detection and intervention to significantly reduce incidence and severity
Key resources
- Ontario Health’s Quality Standard – Pressure Injuries: Care for Patients in All Settings
- Ontario Health’s Pressure Injury Prevention Placemat
- Ontario Health’s Pressure Injury Quality Standard Community of Practice
- RNAO Best Practice Guideline, Pressure injury management: Risk assessment, prevention and treatment
- National Pressure Injury Advisory Panel International Guideline, Prevention and Treatment of Pressure Ulcers/Injuries
- HIROC Mitigation Strategies
- Wounds Canada, Best Practice Recommendations For Skin Health and Wound Management 2025
- Healthcare Excellence Canada, Hospital Harm: Pressure Ulcer
Change Ideas
-
Refine local data collection, and review data regularly
- Review data sources related to pressure injuries to understand your organization’s current state and pressure injury data:
Ontario Health’s Pressure Injuries Quality Standard (HAPI) eReport; requires a ONEID account – please contact QualityandPatientSafety@ontariohealth.ca for assistance
Canadian Institute for Health Information (CIHI) Hospital Harm Project data; overview of “pressure ulcer” rates is available - Refine local processes related to how data is collected, reported, and actioned:
Monitor real-time rates and review your local organizational data, electronic medical records (EMRs), skin assessment reports, incident-reporting systems - Standardize definitions and documentation by implementing an organization-wide standard to identify, stage, and document pressure injuries. Adopt standard criteria for pressure injury stages, define “hospital-acquired,” and use standardized templates across units:
RNAO Best Practice Guideline, Pressure injury management: Risk assessment, prevention and treatment
Build capacity and establish wound care champions to strengthen prevention efforts
- Identify clinical champions (interdisciplinary) to lead initiatives, education, and ongoing support for staff:
Nurses Specialized in Wound, Ostomy and Continence Canada
Wound, Ostomy and Continence Institute, Skin Wellness Associate Nurse (SWAN™) Program - Implement regular interdisciplinary huddles, rounds, and debriefs around skin and wound discussions
- Support accountability and continue to incorporate pressure injury prevention into processes and structures
Standardize assessments and focus efforts on early-risk identification and escalation pathways
- Embed risk assessments (e.g., Braden Scale) into admission process and daily workflows
- Complete risk assessments within 24 hours of admission, with regular re-assessments or re-positioning schedules:
Wounds Canada, Best Practice Recommendations for Skin Health and Wound Management 2025 – provides discussion on assessing/re-assessing
RNAO Best Practice Guideline, Pressure injury management: Risk assessment, prevention and treatment) – provides assessment support, tools, and care bundle - Ensure there are timely dashboards or alert systems/processes for high-risk patients
- Develop clinical pathways and workflows within EMRs for prompting and reminders:
Wounds Canada, Pathway for Preventing and Managing Pressure Injuries
- Review data sources related to pressure injuries to understand your organization’s current state and pressure injury data:
Last Updated: August 26, 2026
