Evaluation of the suitability of root cause analysis frameworks for the investigation of community‐acquired pressure ulcers: a systematic review and documentary analysis

Aims and objectives To evaluate the suitability of root cause analysis frameworks for the investigation of community‐acquired pressure ulcers. The objective was to identify the extent to which these frameworks take account of the setting where the ulcer originated as being the person's home rather than a hospital setting. Background Pressure ulcers involving full‐thickness skin loss are increasingly being regarded as indicators of nursing patient safety failure, requiring investigation using root cause analysis frameworks. Evidence suggests that root cause analysis frameworks developed in hospital settings ignore the unique dimensions of risk in home healthcare settings. Design and methods A systematic literature review and documentary analysis of frameworks used to investigate community‐acquired grade three and four pressure ulcers by home nursing services in England. Results No published papers were identified for inclusion in the review. Fifteen patient safety investigative frameworks were collected and analysed. Twelve of the retrieved frameworks were intended for the investigation of community‐acquired pressure ulcers; seven of which took account of the setting where the ulcer originated as being the patient's home. Conclusion This study provides evidence to suggest that many of the root cause analysis frameworks used to investigate community‐acquired pressure ulcers in England are unsuitable for this purpose. Relevance to clinical practice This study provides researchers and practitioners with evidence of the need to develop appropriate home nursing root cause analysis frameworks to investigate community‐acquired pressure ulcers.