Guest author Dr. Caroline Fife debunks pressure ulcer myths and provides evidence-based strategies for care, policies, and malpractice claim defense.
For decades, clinicians have been taught that pressure ulcers are preventable if only we provide flawless care (e.g., turn patients every two hours, use specialized mattresses, and follow strict skin care protocols, etc.). These assumptions have fueled malpractice claims, driven reimbursement penalties, and created enormous stress for care teams.
As a wound care physician and researcher, the data tell us that it’s time to replace these outdated beliefs and myths.
Key Takeaways:
- Clinicians have been taught that pressure ulcers are always preventable with specific mattresses and strict protocols—but this isn’t true, nor does Medicare believe it’s true.
- A growing body of evidence points to a vascular mechanism behind the formation of pressure ulcers (in fact, the vascular origin of severe pressure ulcers has been understood for more than 30 years).
- Pressure ulcer mitigation strategies may need to include interventions that help manage hemodynamic factors such as oral hydration and blood pressure checks.
What’s In a Name?
Before we address specific myths, it’s important to acknowledge that even the term you’re now told to use to describe the condition, “pressure injuries” (a term not universally accepted), is problematic. Regardless of whether the name change was intended to imply that caregivers “injured” a patient, that is likely what the name implies to patients, families, and jurors.
It's been known for more than 30 years that severe pressure ulcers form from the “inside out” due to vascular events—and not simply from local pressure on the skin. This fact is rarely discussed, and yet it has profound medicolegal implications.
4 Pressure Ulcer Myths That Won’t Die
Here are other important ways I believe we need to shift our thinking around pressure ulcers once and for all.
Myth 1: Ulcers are “never events.”
CMS classifies pressure ulcers under hospital-acquired conditions, but they are not listed among “never events” like wrong-site surgery or retained foreign objects. The false belief that they’re always preventable has fostered a culture of blame.
Myth 2: Turning patients every two hours is mandatory to prevent pressure ulcers.
A large NIH-sponsored trial compared repositioning schedules of two, three, and four hours in nursing home residents. Even among “high-risk” patients, there was no difference in ulcer rates based on turning frequency (when patients had a high-quality foam mattress).1
Myth 3: Ulcers progress from Stage 1 to Stage 4.
Although staging tools imply linear progression, full-thickness ulcers—which include deep tissue injuries (DTIs) and Stage 4 ulcers—often evolve from ischemic damage that has already occurred beneath the surface. By the time discoloration appears, the tissue beneath may already be infarcted and beyond rescue, and the development of a Stage 4 pressure ulcer may be inevitable. In such cases, pressure ulcers “evolve” but do not “progress.” They certainly don’t “progress through the numbers.”
Myth 4: With optimal care, pressure ulcers should never happen.
A prospective study of 63 high-performing long-term care facilities funded by the California Department of Justice showed that residents can develop severe ulcers despite flawless skin care, nutrition, and mobilization. Cardiovascular disease was present in 92%, underscoring the role of systemic illness in ulcer development.2
The Vascular Truth: Pressure Ulcers Form Inside-Out
A growing body of scientific evidence points to a vascular mechanism behind severe pressure ulcers. Tissue supplied by small named arteries and veins—known as angiosomes—can infarct under conditions of hypotension, anemia, or low albumin levels. Depending on the clinical circumstances, these ulcers are “medically unpreventable,” a term that should be used rather than “avoidable” (which is a payment policy term).
Strategies for Care, Policy & Legal Defense
So, now that you know the truth about pressure ulcers, what does this mean in your day-to-day?
- Clinical care: Pressure ulcer mitigation strategies may need to include encouraging oral hydration and even checking blood pressure to help you or your facility avoid being blamed for medically unpreventable events. If hypotension, anemia, or low albumin levels are present, communicate the risk of developing pressure ulcers with the attending physician.
- Documentation: Clinicians should record when ulcers are “medically unpreventable” due to hemodynamic instability, uncorrectable nutritional deficits, or other systemic factors.
- Legal defense: Malpractice defense strategies should highlight that severe ulcers are often ischemic events, forming from the inside out, that “evolve” but don’t “progress.” Clinicians should know that these are not “never” events, that they can occur despite optimal care, and that two-hour patient turning has been debunked for many years.
A Call for a New Paradigm
It’s time to replace the outdated beliefs and myths that all pressure ulcers result from neglect. Full-thickness ulcers (DTIs and Stage 4) should be recognized as vascular events that evolve from the inside out.
By acknowledging that severe pressure ulcers and deep tissue injuries are ischemic in origin, we can move toward policies and practices that are evidence-based, fair to providers, and ultimately better for patients.
Curi Resources
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Watch our on-demand webinar with Dr. Fife for more on this topic: Defending Pressure Ulcer Cases by Understanding How They Really Happen
References:
- Bergstrom, N., Horn, S. D., Rapp, M. P., Stern, A., Barrett, R., & Watkiss, M. (2013). Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes. Journal of the American Geriatrics Society, 61(10), 1705–1713. https://doi.org/10.1111/jgs.12440
- Liao, S. et al. (2010) A Multi-site Study to Characterize Pressure Ulcers in Long-term Care under Best Practices. 231614. https://www.researchgate.net/publication/293958847_A_Multi-site_Study_to_Characterize_Pressure_Ulcers_in_Long-term_Care_under_Best_Practices
Curi’s risk mitigation resources and guidance are offered for educational and informational purposes only. This information is not medical or legal advice, does not replace independent professional judgment, does not constitute an endorsement of any kind, should not be deemed authoritative, and does not establish a standard of care in clinical settings or in courts of law. If you need legal advice, you should consult your independent/corporate counsel. We have found that using risk mitigation efforts can reduce malpractice risk; however, we do not make any guarantees that following these risk recommendations will prevent a complaint, claim, or suit from occurring, or mitigate the outcome(s) associated with any of them.
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