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Study Design <p>Multi-phase root cause analysis (RCA)</p> Objectives <p>Determine the root cause of why veterans developed a novel CAPrI following the completion of the CAPP-FIT intervention from the providers and veterans’ perspectives.</p> Setting <p>A Midwest Veteran Health Administration (VHA) facility SCI clinic.</p> Methods <p>RCA using Five Why’s method and chronology mapping for veterans with spinal cord injury who developed a novel community-acquired pressure injury (CAPrI) following use of a decision support tool to prevent CAPrIs, called the <Emphasis Type="Underline">C</Emphasis>ommunity <Emphasis Type="Underline">A</Emphasis>cquired <Emphasis Type="Underline">P</Emphasis>ressure Injury <Emphasis Type="Underline">P</Emphasis>revention—<Emphasis Type="Underline">F</Emphasis>ield <Emphasis Type="Underline">I</Emphasis>mplementation <Emphasis Type="Underline">T</Emphasis>ool (CAPP-FIT). Data sources include the electronic health record and veteran responses to the CAPP-FIT.</p> Results <p>Key themes emerged describing differing provider/veteran perspectives and barriers that led to the development of a novel CAPrI. Themes included (1) disagreement in level of care needed due to complexity of needs or differing priorities; (2) focus on education and treatment over prevention; (3) barriers in accessing VHA care; and (4) veteran and informal resource engagement.</p> Conclusion <p>CAPrI’s develop quickly, and some can be prevented. Improving the speed that veterans gain access to critical services (e.g., caregiver and specialists), as well as improving communication at the system level (i.e., across VHA facilities and to private facilities) can decrease the risk of CAPrI’s.</p>

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A root cause analysis of community-acquired pressure injuries in persons with spinal cord injuries

  • 期刊论文

  • 发表日期：

    2025年4月22日

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  • Chad M. Osteen,
  • Autumn Smith,
  • Brian Bartle,
  • Reside L. Jacob,
  • Frances Weaver,
  • Sherri L. LaVela,
  • Elizabeth Burkhart

摘要

Study Design

Multi-phase root cause analysis (RCA)

Objectives

Determine the root cause of why veterans developed a novel CAPrI following the completion of the CAPP-FIT intervention from the providers and veterans’ perspectives.

Setting

A Midwest Veteran Health Administration (VHA) facility SCI clinic.

Methods

RCA using Five Why’s method and chronology mapping for veterans with spinal cord injury who developed a novel community-acquired pressure injury (CAPrI) following use of a decision support tool to prevent CAPrIs, called the Community Acquired Pressure Injury Prevention—Field Implementation Tool (CAPP-FIT). Data sources include the electronic health record and veteran responses to the CAPP-FIT.

Results

Key themes emerged describing differing provider/veteran perspectives and barriers that led to the development of a novel CAPrI. Themes included (1) disagreement in level of care needed due to complexity of needs or differing priorities; (2) focus on education and treatment over prevention; (3) barriers in accessing VHA care; and (4) veteran and informal resource engagement.

Conclusion

CAPrI’s develop quickly, and some can be prevented. Improving the speed that veterans gain access to critical services (e.g., caregiver and specialists), as well as improving communication at the system level (i.e., across VHA facilities and to private facilities) can decrease the risk of CAPrI’s.