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Solutions for Patient Safety Fall 2020 Learning Session Abstracts

Journey to Zero Harm for HAPI: “HAPI Hour” Team

Ecklund, Margaret M. MS, RN, CCRN-K, ACNP-BC, WTA-C*; Zimmerman, Krista BS, RN, CCRN

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Pediatric Quality and Safety: March/April 2021 - Volume 6 - Issue - p e444
doi: 10.1097/pq9.0000000000000444
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In fiscal year (FY) 18, 9 of 47 hospital-acquired pressure injuries (HAPIs) were at harm level (stages 3, 4, and unstageable). The reportable HAPI rate was 0.27/1,000 patient days. Data revealed most of our HAPIs are device related, utilized by the interdisciplinary team.


To address the challenge of HAPI reduction and approach the goal of zero harm, we convened an interdisciplinary team, “HAPI Hour” to analyze the data, identify root causes, and approach the solution together.


Our interdisciplinary HAPI Hour committee implemented an evidence-based best practice bundle (BPB) for HAPI prevention. BPB included device padding, rotation, and fit. Our educational plan included tools illustrating appropriate padding and positioning of devices, and the specific elements of the BPB, standard work for HAPI prevention. BPB reliability was measured every shift in all in patient units, via standard work confirmation tool (SWCT). SWCT was completed by the bedside team. BPB reliability revealed challenges. Interdisciplinary teams reviewed barriers to consistent completion. Units posted their SWCT results on whiteboards. All HAPIs, regardless of severity, were reviewed for learning opportunities. Learnings were shared by “Talking Points” posted on each units’ whiteboard, and de-identified pictures of HAPIs were shared with our teams to illustrate learnings.


Since implementation of the BPB and SWCT, the rate of reportable HAPIs dropped from 0.27/1,000 patient days in FY18 to 0.04/1,000 patient days in FY 19, an 85% reduction in reportable HAPIs. Total HAPIs of all stages decreased from 47 to 21, and our device related HAPIs decreased by 59%.


Reducing harm was made possible by building an effective interdisciplinary team that could work at solving the problem of HAPIs together. Team engagement of skin care champions at monthly meetings and unit-level active coaching can create sustained results.

Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.