A root cause analysis of community-acquired pressure injuries in persons with spinal cord injuries.

Study design: Multi-phase root cause analysis (RCA) OBJECTIVES: Determine the root cause of why veterans developed a novel CAPrI following the completion of the CAPP-FIT intervention from the providers and veterans' perspectives.

Setting: A Midwest Veteran Health Administration (VHA) facility SCI clinic.

Methods: RCA using Five Why's method and chronology mapping for veterans with spinal cord injury who developed a novel community-acquired pressure injury (CAPrI) following use of a decision support tool to prevent CAPrIs, called the Community Acquired Pressure Injury Prevention-Field Implementation Tool (CAPP-FIT). Data sources include the electronic health record and veteran responses to the CAPP-FIT.

Results: Key themes emerged describing differing provider/veteran perspectives and barriers that led to the development of a novel CAPrI. Themes included (1) disagreement in level of care needed due to complexity of needs or differing priorities; (2) focus on education and treatment over prevention; (3) barriers in accessing VHA care; and (4) veteran and informal resource engagement.

Conclusion: CAPrI's develop quickly, and some can be prevented. Improving the speed that veterans gain access to critical services (e.g., caregiver and specialists), as well as improving communication at the system level (i.e., across VHA facilities and to private facilities) can decrease the risk of CAPrI's.