Why Pressure Injury Prevention Is Now a Hospital Risk Issue

Pressure injuries are a common clinical issue in hospital systems, yet the impact they have on healthcare organizations is vastly underestimated. In the U.S., more than 3 million pressure injuries are treated each year, and hospital-acquired pressure injuries are associated with substantial health-system and national treatment costs.

While acknowledged as an important issue in terms of patient care, pressure injuries are rarely elevated as an urgent, strategic problem at the executive level. This disconnect exists because pressure injuries are framed as a narrowly defined clinical operational issue that only affects non-ambulatory patients and is managed by specific teams. Early damage is often invisible and the costs are dispersed, so the risk stays off executive dashboards until it escalates. Under the Centers for Medicare and Medicaid Services’ Hospital Acquired Condition Reduction Program, hospitals that fall into the bottom quartile of performance can lose up to one percent of total Medicare reimbursements. 

When pressure injuries are missed or detected late, the consequences extend well beyond the bedside. They trigger additional self-funded treatment costs, financial penalties, legal exposure, added labor strain, and reputational risk. Over time, what appears to be a small clinical problem can quietly become an organizational liability, particularly in systems with Accountable Care Organizations and other risk-based or capitated payment models. In organizational terms, this is a classic “bullwhip” dilemma; even one broken-skin event can create large resource and cost waves later in the episode of care. It results in an inverse cost curve where treatment costs/case drive a total cost burden disproportionate to the scale of problem. 

Nationally, the annual cost of treating hospital-acquired pressure injuries may exceed $26.8 billion. Much of this cost shows up downstream as extended length of stay, additional staff time, wound supplies, and treatment for avoidable complications, and it is often spread across multiple budgets rather than captured as a single line item.  On a per 1,000 patient basis at the national average 3.76% incidence rate, these extended length of stay bed-days, lost revenue as a result of opportunity costs of beds otherwise occupied by HAPI patients, and materials expenses and opportunity costs exceed $3.1mm per year. Many hospital leaders currently underestimate the scale of impact this single issue can have across operations, finance, and workforce stability until they are trying to reconcile spending and resources needs at the end of the year against their annual budgets.

Why the Current Approach Keeps Hospitals Reactive

The core of the issue is how pressure injuries are identified. The prevailing standard of care relies heavily on visual skin assessment, and clinicians are expected to detect damage early enough to intervene before breakdown occurs. But visual and tactile assessment can only detect changes once they reach the skin surface, even though inflammatory changes and tissue edema can occur 3–10 days before visible skin breakdown. Prevention becomes a game of risk- “Is this patient going to develop a pressure injury?”-  rather than a reflection of sub-clinical biological changes to a patient’s skin and tissue.

As pressure injuries develop, early tissue damage occurs beneath the surface of the skin before visible signs appear.  Deterioration may already be significant by the time the injury is detected. Objective measures like sub-epidermal moisture (SEM), also known as Persistent Focal Edema, are designed to detect these nonvisible changes earlier, and studies commonly define elevated SEM delta (Δ ≥ 0.6) as indicating damage at a specific anatomical site.

The current system is inherently reactive and not adequately focal because mitigation efforts begin when damage is visible rather than at the early stages, and early interventions apply to the total body, rather than where the injury is developing. Evidence reviews note that once damage becomes visually apparent, prevention opportunities have often already narrowed because deeper tissue changes have already occurred. Prevention of broken skin pressure injuries, the metric used to define prevention, is therefore too late for the rescue and repair processes to take effect.

This is not a failure of diligence or commitment.  It is a structural limitation: the earliest tissue changes are often happening before there is anything reliable to see, so even well-run teams are forced to act after the fact. That is why prevention can feel inconsistent despite strong training, protocols, and compliance. Predictably, some injuries progress into more complex cases, driving higher costs, longer lengths of stay, and greater organizational risk. What starts as a clinical blind spot quickly becomes an operational challenge. In response, many organizations default to workload-based fixes rather than addressing the underlying detection gap.

When Doing More Increases Risk Instead of Reducing It

Faced with pressure injury risk, many organizations begin asking clinicians to “Do more.” This creates a system of increased assessments, charts, and compliance checks built on top of a faulty detection model.  The outcome is often increased workloads and time demands for nursing teams without any meaningful improvement on patient care. 

A system that depends on clinicians compensating for structural gaps through sheer effort will eventually fail, and when it does the costs surface quickly. Those costs rarely arrive one at a time. Penalties, litigation, staff turnover, and reputational damage will follow, and leadership attention becomes unavoidable.  

The issue shifts from an operational concern to a strategic liability, but only after the damage has already been done.  Much like a pressure injury, what started as small and barely detectable spreads beneath the surface and suddenly spirals into a major crisis. Pressure injuries stop looking like a unit-level clinical issue and start showing up as enterprise risk in the form of quality performance, financial exposure, staffing strain, and public reporting. By the time leadership becomes involved, the organization is often paying for late detection rather than benefiting from early prevention.

The Hidden Organizational Cost of Managing a Complex System and Failures

One reason pressure injuries are underestimated is that much of their true cost remains out of view; Pressure injury prevention is one of the most expensive ‘accepted losses’ in healthcare because a massive pathway has been built around subjective detection, an “uncertainty tax” paid for by health systems.

Over time, hospitals build extensive infrastructure to manage pressure injury risk and treatment. This can include supplies, documentation requirements, and complex workflows designed to respond after damage has already been identified. Each element makes sense in isolation, but together they create a significant operational footprint.  Pressure injuries can carry a wide and unpredictable cost burden which may reach tens of thousands of dollars per episode while consuming practitioner time, supplies, bed days, and quality resources that rarely appear as a single line item. Providers are spending real money on process to compensate for not having a signal. Much of this investment is focused on managing escalation as opposed to early prevention. Because these costs are distributed across labor, supplies, bed utilization, and administrative effort, they are easy to overlook. Leaders may believe they do not have a pressure injury problem when, in fact, they have built an entire system around compensating for late detection. The result is an outsized organizational burden tied to a narrowly defined clinical issue. We tolerate a system where confidence is low, but activity is high.

How High Performing Organizations Think About Prevention

High performing healthcare organizations do not rely on heuristics and heroics to offset predictable system limitations. Instead, they redesign operations to reduce risk earlier.

In pressure injury prevention, using data to look beyond the obvious, worn approaches means shifting focus from reacting to visible damage to identifying risk sooner and acting earlier. When early signals are recognized and addressed, fewer patients progress to advanced injury. The operational shift is simple: move from subjective visual checks to objective early signals that pinpoint risk at specific anatomical sites, so teams can intervene earlier with focused actions instead of adding more blanket assessments and documentation.

The effects cascade throughout the organization as unreimbursed care declines while penalty exposure falls, and legal and insurance risk are reduced. Nursing teams can redirect hours once spent on activities with unknown clinical utility, or managing complex wounds toward direct patient care. Beyond cost avoidance, the organizational impact of prevention is substantial. As resources once consumed by managing burdensome processes and failure are freed, capacity improves, workflows simplify, and workforce strain eases. This is where operations distinguish average organizations from great ones. Strategy sets direction, but it is operational design that determines whether risk is controlled or compounded.

Bringing Risk Into View Before It Becomes a Crisis

Many hospital leaders do not believe they have a pressure injury problem.  The issue often feels contained and managed within routine clinical workflows. Much of the cost, labor, and risk associated with pressure injuries remains hidden within day-to-day operations, surfacing only when something goes wrong.

Bringing that risk into view earlier allows leaders to see pressure injuries as signals of broader system failures as opposed to isolated clinical events. It also shifts prevention from a compliance exercise to an operational design decision that can be measured, managed, and improved.

Pressure injuries may begin as a singular clinical issue, but their impact is much broader. Organizations that recognize this before a crisis hits are better positioned to protect patients, stabilize operations, and reduce avoidable risk. The directive is to act upstream: make the prevention of pressure injuries a strategic issue that is reflective of their system wide impact. This can be accomplished by developing a modernized method of prevention that keeps patients’ skin intact and embedding it as normal practice. Practically this means evolving practice to make early damage visible, standardizing timing of targeted interventions, and embedding a new standard of prevention into daily workflows so it becomes simpler and more consistent at scale.

1. Wassel et al., (2020). Risk of readmissions, mortality, and hospital-acquired conditions across hospital-acquired pressure injury (HAPI) stages in a US National Hospital Discharge database: https://doi.org/10.1111/iwj.13482
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