Legal Aspects of Pressure Ulcer Care

Abstract

Pressure ulcers are serious reportable events that occur in all healthcare settings. Their overall prevalence has not declined dramatically in the past two decades in spite of efforts by multiple government and nongovernmental entities. They account for 45 % of all nursing home litigation in the USA and are a significant proportion of suits filed in other care settings. Tort law as applied to medicine and nursing is designed to deter misconduct and compensate those harmed.

Pressure ulcers are easily recognized, discrete injuries that occur in elderly, frail, and chronically ill people. The individuals affected dwell in complex systems of care and often encounter providers from multiple disciplines. The development of a pressure ulcer that occurs within a system of care not as the result of the action or omission of a single provider is not negligence per se.

To prevail in a malpractice action a plaintiff must show the existence of a doctor–patient relationship, a duty owed to the patient, a breach of the standard of care, and harm. In addition, the alleged harm must be the proximate cause of the injury that prompted the action. Medical experts are needed to offer opinions as to the standard of care particular to the case. Death claims are common in pressure ulcer litigation (approximately 30 %). Malpractice claims can be defended by contesting liability for the undesired outcome, on the amount of alleged damages or both. Many claims are settled pre-suit and most do not go to trial.

Most wound care professionals agree that some pressure ulcers are unavoidable. Identifying patients at risk and applying focused preventative strategies are the duty of the providers in a care system. Developing a reasoned plan of care and effectively applying devices to prevent injury are also part of that duty.

Evidence-based clinical practice guidelines may add value to the care process. Good quality evidence for effective prevention and treatment is lacking. Therefore providing a firm basis for the applicable standard of care is difficult and most often left to expert opinion. In addition to practice guidelines, state practice acts and facility policy and procedures may be used as evidence.

The legal route to dispute resolution is a lengthy and arduous process. Anger, fear, and guilt often drive plaintiffs to initiate a case. Defendants are the second victims when a case is filed. Open two-way communication between patients and providers is the proper approach in any clinical situation. It is also the best malpractice avoidance tool yet devised.