Pressure Ulcer Risk Assessment Audit

This project audits whether people at risk of pressure ulcers are identified and assessed within the locally agreed timeframe using the locally approved tool, whether skin assessment and any existing damage are documented, whether reassessment follows clinical change or transfer, and whether an individualised prevention plan covering repositioning, support surfaces, heel offloading, nutrition, continence and device-related risk is recorded. It also reviews tissue viability escalation, patient and carer information, incident reporting, safeguarding consideration, transfer communication and follow-up.

• Nurses, AHPs, doctors and support staff completing pressure ulcer risk and skin assessments
• Tissue viability, frailty, orthopaedic and critical care teams
• Care-home, hospice, community nursing and GP practice clinical teams
• QI leads, governance and patient safety teams
• Supervisors and educators supporting ARCP and appraisal evidence

• Measure completion and timeliness of pressure ulcer risk assessment
• Assess skin assessment quality and documentation of existing damage
• Review individualised prevention planning, repositioning and equipment decisions
• Test escalation, incident reporting, safeguarding consideration and transfer communication
• Generate governance-ready and ARCP-ready evidence and a re-audit cycle

• Anonymous case identifier
• Inclusion / eligibility decision
• Anonymised context (age band, sex/gender recorded, care setting, pressure ulcer risk context)
• Clinical area / location and optional specialty / service
• Twenty-three pressure ulcer prevention criteria (met / not met / not applicable)
• Free-text learning points and any project custom fields

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

This ready-built project is developed using the guidance, standards and authoritative sources listed below, so you can see what is being measured and why. Lazomis QI does not publish or own this guidance, and inclusion here does not imply endorsement or approval by any of these organisations.

• NICE

  CG179: Pressure ulcers — prevention and management(opens the original source in a new tab)

  Sets out expectations for risk assessment, skin assessment, prevention planning, repositioning, support surfaces and escalation.

• NICE

  QS89: Pressure ulcers(opens the original source in a new tab)

  Quality statements covering risk assessment, skin assessment, prevention plans and repositioning for people at risk.

• DHSC / GOV.UK

  Pressure ulcers: how to safeguard adults(opens the original source in a new tab)

  Guidance on when pressure damage should prompt safeguarding consideration. Safeguarding decisions remain a local clinical and safeguarding process.

• GOV.UK / OHID

  All Our Health: Pressure ulcers(opens the original source in a new tab)

  Prevention-focused resource for frontline teams, useful where locally adopted for education and improvement work.

• NHS England

  Recording patient safety events and levels of harm(opens the original source in a new tab)

  National context for recording patient safety events (LFPSE) where pressure ulcer incident reporting is locally relevant. Local reporting thresholds apply.

• NHS England / NWCSP

  National Wound Care Strategy Programme — pressure ulcer resources(opens the original source in a new tab)

  Recommendations and resources for pressure ulcer prevention pathways, where locally adopted.

• Local policy

  Local pressure ulcer prevention, equipment, tissue viability and safeguarding policies

  Local pressure ulcer prevention and management policy, risk assessment tool guidance, skin inspection standard, repositioning policy, support-surface and heel offloading pathways, nutrition and hydration policy, continence and moisture-associated skin damage guidance, tissue viability referral pathway, incident reporting policy, safeguarding adults policy, community and care-home escalation pathways, discharge and transfer communication standard and EPR documentation guidance define what is required locally. Confirm local policy before setting targets.

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports documentation and risk-assessment review only. It does not provide patient-specific wound care, tissue viability, equipment or safeguarding advice.
• Risk scores, thresholds, assessment timeframes, repositioning intervals, equipment rules and referral or reporting triggers are locally configured and are not presented here as national standards.
• Avoidability, neglect and harm cannot be determined from audit data alone; local incident and safeguarding processes apply.
• Use anonymous case identifiers only — never patient-identifiable information.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Clinical GovernanceLeveraging Incident Themes for Quality Improvement and Patient SafetyThis guide helps NHS teams identify and analyse recurring incident themes, transforming reported safety events into practical quality improvement opportunities to enhance patient safety and system reliability.
• Patient SafetyIntegrating Patient Safety and Quality Improvement: A Practical Guide for UK CliniciansThis guide explains the foundational principles of patient safety and quality improvement (QI) within the UK healthcare context, offering practical strategies for clinicians to enhance safety and improve care delivery.
• Patient SafetyHow to Select a Patient Safety Quality Improvement ProjectThis guide helps NHS teams identify and select patient safety quality improvement (QI) projects that are impactful, achievable, and aligned with organisational and national priorities. Learn how to move from identifying concerns to choosing a focused and measurable project.
• Quality ImprovementDocumenting PDSA Cycles for Effective Quality ImprovementThis guide provides practical advice on documenting Plan-Do-Study-Act (PDSA) cycles, a crucial component of effective quality improvement in the NHS, ensuring learning is captured and shared.