NURS-FPX 4020 – Assessment 2: Assessing the Problem – Quality, Safety, and Cost of Care

Assessment overview

In Assessment 2, write a focused 4–6 page paper that critically examines a significant quality and safety problem in your chosen health care setting and evaluates its impact on patient outcomes, staff practice, and organisational costs.

Work from a clearly defined, real or realistically constructed problem (for example, hospital-acquired infections, avoidable readmissions, falls, pressure injuries, or diagnostic delay) rather than a vague description, and show how quality, safety, and cost dimensions intersect in everyday practice.

Assessment context

Quality and safety issues such as medication errors, falls, infections, and communication failures remain common drivers of preventable harm, poor patient experience, and waste in health systems internationally.

Nurses are central to detecting problems early, interpreting data, and working with interprofessional colleagues to design improvement strategies that also consider resource use and cost implications.

This assessment builds on your earlier work on medication-administration safety by asking you to step back and assess a broader quality and safety problem through the lenses of patient outcomes, risk, workflow, and financial impact.

Assessment instructions

1. Select a quality and safety problem

Choose a specific, clearly defined quality and safety problem in a real or well-constructed practice setting, such as:

• High rates of hospital-acquired infections (for example, catheter-associated urinary tract infection, central line–associated bloodstream infection, or surgical site infection).

• Inpatient falls with injury on a medical-surgical or geriatric ward.

• Unplanned 30-day readmissions for a chronic condition such as heart failure or COPD.

• Pressure injuries in an intensive care, aged care, or rehabilitation setting.

• Delays in diagnostic testing or results communication leading to treatment delays.

Ensure you can access or reasonably describe data, workflow, and stakeholders relevant to the problem in your chosen setting.

2. Describe the practice context and problem (quality and safety focus)

In the first section of your paper:

i. Describe the practice setting and population.
Outline the type of organisation (for example, acute care hospital, community health service, primary care clinic, aged care facility), typical patient population, and any relevant organisational characteristics such as staffing patterns, models of care, technology in use, or safety culture indicators.

ii. Describe the quality and safety problem in precise terms.
Specify what is happening or has happened, who is affected, and how frequently the problem occurs where data are available (for example, incidence rates, trend data, or benchmark comparisons).

iii. Explain why this problem is a priority.
Link the problem to patient harm, risk, regulatory or accreditation expectations, and strategic priorities (for example, national safety and quality standards or organisational goals).

3. Analyse factors contributing to the problem (quality, safety, and cost)

Provide an evidence-informed analysis of human, system, and environmental factors that drive or sustain the problem.

i. Human factors.
Discuss staff-level contributors such as knowledge gaps, workload, fatigue, communication patterns, role clarity, and attitudes to reporting or safety.

ii. System and process factors.
Analyse policies, procedures, documentation systems, handoff processes, staffing models, and leadership practices that shape how care is delivered and how errors or adverse events occur.

iii. Environment and technology.
Consider physical layout, equipment and device usability, health IT systems (for example, electronic health records, bar-code medication administration, decision support), and organisational culture around safety reporting and learning.

iv. Potential outcomes if the problem persists.
Explain likely consequences for patients (for example, morbidity, mortality, functional decline, experience), staff (for example, moral distress, workload), and the organisation (for example, length of stay, readmissions, reputational risk, financial penalties).

4. Evaluate the cost implications of the problem

Using available literature and any local or benchmark data, evaluate how the identified problem affects direct and indirect costs.

• Describe direct clinical and operational costs associated with the problem (for example, extended hospitalisation, additional treatments, investigations, staffing time).

• Identify indirect costs such as lost productivity, litigation risk, regulatory penalties, and downstream use of health services.

• Where possible, draw on published estimates of cost per event or per case to illustrate the financial weight of the problem for the organisation or health system.

5. Link the problem to quality-improvement opportunities

In the final analytical section, connect your assessment of the problem to realistic quality-improvement opportunities.

i. Summarise relevant evidence-based guidelines, safety standards, or quality frameworks (for example, national safety and quality standards, WHO or AHRQ resources, specialty society guidance).

ii. Identify where current practice in your setting aligns with or deviates from these standards.

iii. Briefly indicate one to two areas where a targeted quality-improvement initiative (which you will fully develop in a later assessment) could reasonably reduce risk, improve quality, and generate cost savings.

6. Academic writing and format requirements

• Length: 4–6 pages of scholarly narrative (excluding title page and reference list).

• Format and style: Use current APA style for formatting, headings, in-text citations, and references.

• Sources: Include at least 4–6 current, peer-reviewed scholarly sources published between 2018 and 2026 that directly support your analysis of the problem’s quality, safety, and cost dimensions.

• Writing quality: Organise the paper logically with clear headings, explicit links between ideas, and precise, professional language consistent with upper-level BSN expectations.

Scoring guide (marking criteria)

Criterion 1: Explain a significant quality and safety problem in a specific practice setting

• Exemplary: Provides a clear, well-defined explanation of a specific quality and safety problem within a distinct practice context, integrating organisation and population details to demonstrate its significance.

• Proficient: Clearly describes a quality and safety problem and basic contextual factors.

• Needs improvement: Description is vague, generic, or missing critical contextual details.

Criterion 2: Analyse factors that contribute to the problem and potential outcomes

• Exemplary: Critically analyses human, system, and environmental factors contributing to the problem and connects them to plausible patient, staff, organisational, and cost outcomes, supported by current evidence.

• Proficient: Identifies and explains key contributing factors and outcomes with reasonable clarity.

• Needs improvement: Provides limited or superficial analysis of contributing factors and outcomes, or relies on minimal evidence.

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Criterion 3: Evaluate the cost implications of the quality and safety problem

• Exemplary: Provides a clear, evidence-based evaluation of direct and indirect costs associated with the problem, integrating published estimates where available and linking cost to quality and safety performance.

• Proficient: Describes key cost implications with some use of evidence.

• Needs improvement: Mentions costs only briefly or generically, with little supporting evidence.

Criterion 4: Link the problem to quality-improvement opportunities

• Exemplary: Clearly connects the assessed problem to evidence-based standards and identifies realistic opportunities for targeted quality-improvement work that address both safety and cost.

• Proficient: Identifies plausible QI opportunities related to the problem, supported by appropriate evidence.

• Needs improvement: QI opportunities are vague, poorly aligned with the problem, or lack a clear evidence base.

Criterion 5: Demonstrate scholarly, professional writing in APA style

• Exemplary: Writing is logically organised, concise, and precise, with virtually no grammatical or spelling errors; citations and references consistently follow current APA style.

• Proficient: Writing is generally clear and mostly free of errors; APA style is mostly correct.

• Needs improvement: Frequent errors in mechanics or APA style that interfere with clarity or professional tone.

Hospital-acquired pressure injuries in an intensive care unit represent a persistent quality and safety problem that affects some of the most physiologically vulnerable patients and generates substantial preventable cost for organisations. Critically ill patients often have limited mobility, require vasoactive medications, and are supported by multiple devices, all of which increase tissue-injury risk when repositioning protocols and skin-integrity assessments are inconsistently applied. Published evidence shows that structured prevention bundles, early risk identification tools, and reliable documentation practices can reduce pressure-injury incidence and associated treatment costs, which makes this problem an appropriate focus for a quality, safety, and cost assessment in a BSN-level course on improving care outcomes.

From a systems perspective, persistent quality and safety problems often reflect gaps between policy and practice rather than isolated individual failures. High-reliability health care literature emphasises that sustainable improvements in safety and cost control depend on consistent use of data, frontline staff engagement, and leadership commitment to learning from adverse events rather than assigning blame. When organisations integrate routine safety measurement with cost awareness, nurses are better positioned to advocate for changes that improve patient outcomes while also reducing avoidable expenditure (Agency for Healthcare Research and Quality, 2020).

Reference

Agency for Healthcare Research and Quality. (2020). Patient safety and quality improvement. U.S. Department of Health and Human Services. https://www.ahrq.gov/patient-safety

#Sample Answer

Hospital-Acquired Pressure Injuries in Intensive Care:

Assessing Quality, Safety, and Cost Implications

Student Name

Capella University

NURS-FPX 4020: Improvement of Quality and Safety

Instructor Name

January 28, 2026

 

Hospital-Acquired Pressure Injuries in Intensive Care: Assessing Quality, Safety, and Cost Implications

Pressure injuries acquired during hospitalisation remain among the most common preventable harms in acute care, with intensive care units reporting incidence rates between 10 and 25 per cent despite widespread awareness of risk factors and prevention protocols (Alderden et al., 2021). Critically ill patients face compounded vulnerability from haemodynamic instability, sedation, mechanical ventilation, and device-related pressure, yet staff workload and competing priorities frequently result in inconsistent repositioning and skin assessment practices. A 20-bed medical-surgical intensive care unit at a 350-bed regional teaching hospital documented 18 stage 2 or higher hospital-acquired pressure injuries during the last six months of 2025, representing an incidence rate of 14 per cent among patients with ICU stays exceeding 72 hours. Root cause analyses revealed that turning schedules were documented but not reliably executed during high-acuity periods, and risk assessment tools were completed at admission but rarely updated when patient conditions changed. Nursing staff acknowledged gaps between written protocols and actual bedside practice, attributing delays to unstable patients, limited lift equipment access, and difficulty coordinating turns during procedures or family visits.

Practice Context and Population

The unit serves adults requiring mechanical ventilation, vasoactive medication support, continuous renal replacement therapy, or post-cardiac surgery monitoring. Average patient age is 62 years, with common diagnoses including sepsis, acute respiratory failure, cardiogenic shock, and multi-organ dysfunction. Nurse-to-patient ratios range from 1:1 for the most unstable cases to 1:2 for patients approaching step-down criteria. The unit implemented a pressure-injury prevention bundle in 2023 that includes Braden Scale assessment at admission and every 48 hours, two-hour repositioning schedules documented in the electronic health record, use of pressure-redistribution surfaces for patients scoring below 13, and daily skin inspections during morning rounds. Despite these protocols, compliance audits conducted in November 2025 showed that repositioning occurred on schedule only 62 per cent of the time, and Braden Scale reassessments were completed for just 54 per cent of eligible patients.

Staff surveys revealed that nurses understood the clinical importance of pressure-injury prevention but felt protocols were designed without accounting for real-time demands. Patients requiring prone positioning for acute respiratory distress syndrome, those on extracorporeal membrane oxygenation, and individuals with multiple invasive lines presented particular challenges. Nurses described situations where turning a patient required three or four staff members, yet the charge nurse roster showed frequent periods when only two available nurses could step away from their assigned patients. Equipment availability also posed obstacles. The unit possessed six motorised lateral-rotation beds and four alternating-pressure overlays, but demand exceeded supply during high-census weeks. Patients awaiting specialty surfaces sometimes spent 12 to 24 hours on standard ICU mattresses while at elevated risk.

Quality and Safety Problem Definition

Hospital-acquired pressure injuries in the ICU setting constitute a never event under many regulatory frameworks and are explicitly addressed in national safety and quality standards. The 18 documented cases included 11 stage 2 injuries, five stage 3 injuries, and two unstageable injuries discovered after debridement of necrotic tissue. Anatomical locations clustered on the sacrum, heels, and occiput, with three device-related injuries attributed to endotracheal tube holders and continuous positive airway pressure masks. Fourteen of the 18 injuries were identified during routine skin assessments, while four were reported by family members who noticed redness or skin breakdown during visits. Photographic documentation confirmed that 12 injuries were present within 72 hours of ICU admission, suggesting rapid tissue damage in high-risk patients.

The problem qualifies as a priority for several reasons. Pressure injuries cause pain, delay mobilisation, extend ICU and hospital length of stay, and increase infection risk when skin integrity is compromised (Mervis & Phillips, 2019). Regulatory bodies link pressure-injury rates to quality rankings and reimbursement, with hospitals facing financial penalties when stage 3 or higher injuries occur during admission. The organisation’s strategic plan for 2025 to 2027 identifies pressure-injury reduction as a top-five patient safety goal, aligning with broader efforts to achieve high-reliability status and improve patient-reported outcomes. Unit leadership expressed concern that persistent pressure injuries undermine staff morale and contradict the unit’s commitment to evidence-based care.

Contributing Factors: Human, System, and Environmental

Human factors operate at multiple levels within the ICU pressure-injury problem. Nursing knowledge about pressure-injury pathophysiology and prevention strategies is generally strong, but translating that knowledge into consistent action proves difficult under high cognitive load. Nurses manage ventilator alarms, titrate vasopressors, coordinate with respiratory therapists and physicians, respond to family questions, and document multiple interventions simultaneously. In some ways, pressure-injury prevention competes with tasks perceived as more immediately life-threatening, even though delayed repositioning creates harm that accumulates gradually rather than acutely. Communication gaps between shifts contribute to inconsistency. Handoff reports focus on haemodynamic status, sedation levels, and pending procedures, with skin integrity and turning schedules receiving brief mention or none at all.

System and process factors shape how prevention protocols function in practice. The two-hour repositioning standard originates from evidence developed in lower-acuity settings and may not reflect the complexity of turning a patient on multiple vasopressors with an open chest or a patient receiving extracorporeal support. Written policies do not provide clear guidance on how to adapt repositioning schedules when patient instability makes turning unsafe or when staffing shortages prevent assembling the required team. Documentation systems create additional friction. Nurses must navigate multiple screens in the electronic health record to locate the repositioning flowsheet, and the system does not generate automatic alerts when turns are overdue. Pressure-redistribution surface allocation follows a first-come, first-served approach rather than a structured risk-based protocol, leaving some high-risk patients on standard surfaces while lower-risk patients occupy specialty beds.

Environmental and technology factors add complexity. ICU rooms are designed around monitoring and life-support equipment rather than safe patient handling. Limited space around beds makes it difficult to position lifts or gather the team needed for safe repositioning. Specialty surfaces are stored in a central equipment room two corridors away from the unit, requiring staff to leave the bedside to retrieve them and delaying implementation of prevention strategies.床边 electronic health record terminals are positioned on mobile carts that must be moved when staff reposition patients, creating workflow interruptions. Organisational culture around safety reporting influences how pressure injuries are perceived and addressed. Staff worry that reporting a newly identified injury will be interpreted as individual failure rather than a system problem, which discourages early identification and transparent discussion of prevention breakdowns.

Potential Outcomes if the Problem Persists

Unaddressed pressure injuries produce cascading consequences for patients, staff, and the organisation. Patients experience pain that complicates sedation weaning and rehabilitation, and open wounds increase susceptibility to infection in an already immunocompromised population. Stage 3 and stage 4 injuries require surgical debridement, advanced wound care products, and extended hospital stays that delay return to functional independence (Mervis & Phillips, 2019). Families report distress when they discover injuries that developed during critical illness, and some pursue formal complaints or litigation when they believe preventable harm occurred.

Staff face moral distress when protocols they believe in cannot be reliably executed because of system constraints. Nurses describe feeling caught between competing demands and frustrated when injuries occur despite their awareness of prevention strategies. Persistent pressure injuries contribute to burnout and turnover, particularly among newer staff who entered the profession expecting to prevent harm rather than document it after the fact. The organisation absorbs direct costs from extended ICU and hospital length of stay, costs that are not reimbursed when pressure injuries are hospital-acquired. Regulatory agencies and accreditation bodies scrutinise pressure-injury data during surveys, and poor performance can result in citations, corrective action plans, or reputational damage that affects patient volume and payer contracts.

Cost Implications of Hospital-Acquired Pressure Injuries

Direct clinical costs associated with hospital-acquired pressure injuries are substantial and well documented in health economics literature. Padula et al. (2019) estimated that each stage 2 pressure injury adds approximately 10,000 dollars in treatment costs, while stage 3 and stage 4 injuries increase costs by 43,000 to 129,000 dollars per case when accounting for wound care supplies, additional nursing time, surgical interventions, extended length of stay, and infection management. Applying these figures to the 18 injuries documented in the unit during the latter half of 2025 suggests total direct costs between 400,000 and 600,000 dollars, depending on injury severity and subsequent complications. Advanced wound dressings alone can cost between 50 and 200 dollars per application, with dressing changes required daily or multiple times per day for deeper injuries.

Extended ICU length of stay represents the largest single cost driver. Sullivan and Schoelles (2013) found that patients who develop pressure injuries remain hospitalised an average of four additional days compared to similar patients without injuries, with ICU days costing between 3,000 and 5,000 dollars per day at most institutions. Indirect costs amplify the financial burden. Organisations face penalties under value-based purchasing programs when pressure-injury rates exceed established thresholds, with potential reimbursement reductions of up to 2 per cent of total Medicare payments. Litigation costs, while difficult to quantify precisely, can reach hundreds of thousands of dollars in settlements when families pursue claims related to pressure injuries that progressed to stage 4 or resulted in sepsis.

Opportunity costs deserve consideration as well. Nursing time spent managing established pressure injuries represents time unavailable for prevention activities or other patient care priorities. When ICU beds remain occupied by patients recovering from pressure-injury complications, elective surgical cases may be delayed or diverted to other facilities, reducing revenue and harming the organisation’s competitive position. Thus, the true cost of uncontrolled pressure-injury incidence extends beyond direct medical expenses to encompass regulatory risk, reputational impact, and forgone opportunities for higher-value care delivery.

Quality Improvement Opportunities

Evidence-based guidelines from organisations such as the National Pressure Injury Advisory Panel and the Agency for Healthcare Research and Quality emphasise structured prevention bundles that combine risk assessment, repositioning protocols, pressure-redistribution surfaces, skin inspection, and interprofessional collaboration (Alderden et al., 2021). Current practice in the unit aligns with guideline recommendations on paper but demonstrates implementation gaps during high-acuity periods and staffing shortages. Compliance audits reveal specific vulnerabilities in Braden Scale reassessment, timely access to specialty surfaces, and documentation of repositioning rationale when turns are delayed or modified because of patient instability.

Targeted quality-improvement opportunities exist in at least two areas. First, implementing an electronic health record alert system that flags patients with Braden scores below 13 and overdue repositioning could prompt timely intervention and support more reliable protocol adherence. Research by Tayyib and Coyer (2016) demonstrates that automated reminders improve repositioning compliance when integrated into workflow rather than adding steps. Second, developing a risk-stratified allocation protocol for pressure-redistribution surfaces would ensure that the highest-risk patients receive specialty beds within defined timeframes, reducing delays that currently occur under first-come, first-served systems. Both initiatives address identified gaps, align with evidence-based standards, and could generate measurable reductions in pressure-injury incidence alongside associated cost savings.

Conclusion

Hospital-acquired pressure injuries in intensive care settings represent a persistent quality and safety problem driven by complex interactions among human, system, and environmental factors. High-acuity patients face elevated risk from haemodynamic instability and immobility, yet prevention protocols designed for general ward populations do not account for the challenges of turning critically ill individuals safely and consistently. Direct costs per injury range from 10,000 to over 100,000 dollars, with additional indirect costs from regulatory penalties, extended length of stay, and litigation risk. Evidence-based guidelines provide clear direction for prevention, but implementation gaps persist when workflow design, staffing models, and technology systems do not support reliable execution. Targeted quality-improvement initiatives focused on automated risk alerts and structured allocation of pressure-redistribution surfaces offer realistic pathways to reduce injury rates and associated costs while improving patient safety and staff satisfaction.

 

References

Alderden, J., Zhao, Y. L., Zhang, Y., Thomas, D., & Butcher, R. (2021). Outcomes associated with hospital-acquired pressure injuries: A systematic review. Advances in Skin & Wound Care, 34(10), 1–14. https://doi.org/10.1097/01.ASW.0000751409.26879.0a

Mervis, J. S., & Phillips, T. J. (2019). Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. Journal of the American Academy of Dermatology, 81(4), 881–890. https://doi.org/10.1016/j.jaad.2018.12.069

Padula, W. V., Pronovost, P. J., Makic, M. B. F., Wald, H. L., Moran, D., Mishra, M. K., & Meltzer, D. O. (2019). Value of hospital resources for effective pressure injury prevention: A cost-effectiveness analysis. BMJ Quality & Safety, 28(2), 132–141. https://doi.org/10.1136/bmjqs-2017-007505

Sullivan, N., & Schoelles, K. M. (2013). Preventing in-facility pressure ulcers as a patient safety strategy: A systematic review. Annals of Internal Medicine, 158(5_Part_2), 410–416. https://doi.org/10.7326/0003-4819-158-5-201303051-00008

Tayyib, N., & Coyer, F. (2016). Effectiveness of pressure ulcer prevention strategies for adult patients in intensive care units: A systematic review. Worldviews on Evidence-Based Nursing, 13(6), 432–444. https://doi.org/10.1111/wvn.12177