This is a secondary driver from leadership at all levels to support a culture of safety within the Pressure Ulcers driver diagram
Change ideas
The examples below show how this secondary driver can be implemented in practice. Additional change ideas can be found in the Pressure Ulcers driver diagram
Practitioner:
- Accessing shared learning through formal and informal networks
Team:
- Use of locally agreed pressure ulcer investigation tool and agreed communication strategies to share learning for improvement
- Test ideas for improvements within an agreed timeframe
Organisation:
- Use of systems to capture reliable pressure ulcer data to be shared with all staff to inform improvement
- Local and organisational level reporting for learning
Evidence and resources
- Clark M, Young T, Fallon M. Systematic review of the use of Statistical Process Control methods to measure the success of pressure ulcer prevention. International Wound Journal. 2018;15,391-401
- Healthcare Improvement Scotland. A national framework for reviewing and learning from adverse events in NHS Scotland [online]. 2025
- Healthcare Improvement Scotland. Learning system [online]
- Healthcare Improvement Scotland. Scottish Approach to Change [online]
- Healthcare Improvement Scotland. The engagement practice learning and improvement system [online]
- Healthcare Improvement Scotland. HIS SPSP Adults in Hospital MS Teams Channel Registration Form – Fill out form [online]. 2025
- NHS Education for Scotland. Quality Improvement Learner Pathways [online]
- Right Decision Service. Quality of care review guidance [online]. 2024
