STOP SORE - Say “NO” to Pressure Injury
Care Process & Redesign
Yishun Health One Improvement Festival
National Healthcare Group
8 April 2025
Reduce the risk of hospital-acquired pressure injury by strengthening staff awareness and adherence to prevention protocols. The initiative was adopted across all wards, engaging PI auditors in overseeing execution and ensuring long-term sustainability.
Year Submitted: 2025
Published Date: 08 April 2025
Tags: Value Based Care, Safe Care, Preventive Approach, Risk Management, Care Process ＆ Redesign
About this Content
Aims
Reduce the risk of hospital-acquired pressure injury by strengthening staff awareness and adherence to prevention protocols.
Background
Before the project, audits revealed frequent lapses in pressure injury prevention interventions. A survey conducted in July 2024 identified root causes such as unfamiliarity with interventions based on the Braden score and communication delays.
Methods
The project involved assigning patients into care streams, engaging patients and caregivers, managing frailty, and ensuring quality and patient safety through corrective measures. Operational resilience was also emphasized.
Results
The 'STOP SORE' Kaizen was successfully implemented, leading to increased staff compliance with prevention interventions. Internal audits were conducted three times a week, and monthly PI audits were performed.
Conclusion
The initiative was adopted across all wards, engaging PI auditors in overseeing execution and ensuring long-term sustainability. Continuous feedback collection remains a priority for improvement.
Lessons Learnt
Staff gained increased confidence, felt more empowered, and developed a deeper understanding of the importance of PI interventions.
Additional Information
The project included creating an acronym for common interventions, printing decision metrics, updating Braden scores, attaching laminated checklists, and spreading the Kaizen to other wards.
Keywords
Pressure Injury, Prevention, Nursing, Patient Safety, Kaizen
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Yishun Community Hospital |
Platform(s) | Yishun Health One Improvement Festival |
Healthcare Professional Group(s) | Nursing |
Applicable Specialty or Discipline | General Medicine, Wound Care Medicine |
Project Lead(s) | Tan Poh Yin |
Project Member(s) | Tham Hui Ming |
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KTPH & YCH Innovation & Improvement (I&I) Office - i-i@ktph.com.sg