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hospital-acquired pressure injury, pink paper, pressure injury, pressure injury prevention, reminder system, risk assessment tool, risk score



  1. Shieh, David C. MD
  2. Berringer, Christine M. MSN
  3. Pantoja, Roselyn MSN
  4. Resureccion, Juji MSN
  5. Rainbolt, Joria M. MSN
  6. Hokoki, Amena MD


OBJECTIVE: The goal of this quality improvement project was to reduce the number of hospital-acquired pressure injuries (HAPIs) by flagging extremely high-risk patients with a pink paper reminder system and implementing a pressure injury prevention order set.


METHODS: The pink paper reminder system is an innovative, cost-neutral, simple approach to identify patients at highest risk of pressure injury development who meet specific criteria. There are 2 steps to this intervention. First, study authors developed a new risk assessment tool, the pink paper criteria. When a patient met the specified criteria, a pink piece of paper titled "SKIN AT RISK" in a large font was hung at the head of his/her bed to reinforce preventive strategies. Next, a set of pressure injury preventive measures was ordered.


PATIENTS: This quality improvement project included all adult hospitalized patients of all specialties based in 2 Kaiser Permanente hospitals.


RESULTS: There was a 67% reduction in HAPI incidences following the initiation of the pink paper reminder system, from a mean rate of 1.2 to 0.4 incidence of HAPIs per 1000 patient-days measured over 4 years.


CONCLUSIONS: Identifying and flagging patients who are at extremely high risk of pressure injuries and implementing an order set of pressure injury preventive measures dramatically reduced the rate of HAPIs per 1000 patient-days.