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"Cluster" review process: investigating grade 3 and 4 pressure ulcers to reduce patient harm and improve patient care.

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NHS Fife recognises pressure damage as a key harm and strategic priority. A Cluster meeting is a critical review of acquired Grade 3 and 4 pressure ulcers, considered major harm.



The meeting is chaired by a senior nurse. The ward team attends, nurse manager, tissue viability nurse, podiatrist, clerical support. More than one case is reviewed at each meeting, hence the term “cluster”. Meetings are held monthly to facilitate a timely review. Following an initial SBAR report, the NHS Fife Rapid Event Investigation (REI) tool is used to investigate the incident at ward level. This information is presented at cluster by the ward representative.




The review focuses on learning and establishing common themes to improve patient care, this is shared throughout NHS Fife. Whilst it is a critical review the emphasis is not on attributing blame. Each case receives an expert and peer review. Ward teams find the meeting challenging but generally a positive experience. This was determined during an evaluation of the process. Outcomes and actions, both local and organisational are recorded on the incident reporting system (datix).



Prior to the Cluster meetings, incidents were investigated locally. It was challenging to arrange a timely review and learning was not shared widely. Opportunities for change were missed. Senior nurse leadership and support has been a crucial factor in the success of the Cluster. A standard operating procedure (SOP) on the Cluster meeting was developed to support staff attending. Learning and common themes focus the education provided by the tissue viability service. Outcomes from the meetings have led to the development of a pressure ulcer grading tool video, pocket grading tool cards for community nurses. A poster was developed “Be Aware of Pressure Area care” as a pressure ulcer pathway for clinical areas. The current risk assessment tool (PURA) and SSKIN bundle were updated. The PURA was adapted for use in mental health. The Tissue Viability Times newsletter circulated bi-monthly highlights learning from the Cluster meetings held across NHS Fife.



Cluster meetings have become an integral part of pressure ulcer prevention strategies within NHS Fife. A timely review of multiple cases optimises immediate improvements in patient care. A review of themes demonstrates that improvements have been made. Discussions between clinical areas are more open and part of normal dialogue. Ongoing challenges for the future include determining whether the pressure ulcer is avoidable or unavoidable and including this information within the pressure ulcer count. The ultimate aim is to investigate harm in a robust manner with positive discussions to improve patient care.

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