Reducing Pressure Injuries in Hospitals

Pressure injuries (formerly called pressure ulcers) are considered preventable by Centers for Medicare & Medicaid services (CMS), but they still happen despite high standards of care. They are debilitating, painful, and expensive. Hospital-acquired stage 3 and 4 pressure injuries cost $70,000 to $150,000 and are not reimbursed by CMS. Each year, 2.5 million patients suffer from varying stages of pressure injures at a cost of about $12 billion. About 60,000 patients die as a direct result of pressure injuries each year.

It has long been established that the key to preventing pressure injuries is prompt recognition of risk factors and early initiation of prevention measures. Factors in assessing patient risk include position, nutrition, and skin condition.

Pressure injuries can be avoided by adhering to well-established prevention practices, including regular patient repositioning, skin and nutrition assessment, and use of specialty surfaces. So why do pressure injuries still occur? A major US health system employed the Amplifire training tool to acquire data on what its nurses knew and didn’t know about pressure injury prevention strategies, and to find and fix any misinformation.


  • 9,893 instances of CHM found and fixed
  • 1,902 instances of uncertainty found and fixed
  • The variation of knowledge was high, with some nurses quite misinformed and others showing confident mastery of the topic. The most knowledgeable were 100 percent confident and correct about pressure injuries. The least show that misinformation occupied up to 50 percent of their knowledge
  • Nurses who were most misinformed or uncertain spent nearly a half hour in the module, while nurses who were most knowledgeable about pressure injuries spent about 19 minutes
  • By the end of the course, 100% of the nurses who completed were confident and correct on all the information

Confidently Held Misinformation and Implications

Amplifire found a significant amount of confidently held misinformation (CHM) around nutrition factors, distinguishing pressure injuries and IAD (Incontinence Associated Dermatitis), and other environmental factors. Complete the form below to download the full case study and learn about the clinical implications.