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

Spinal Cord Series and Cases volume 11, Article number: 11 (2025) Cite this article

Subjects

Abstract

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.

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Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Funding

Funded by the VA HSR&D, IIR 16-267 Engaging Patients and Providers in Identifying and Addressing Modifiable Risk Factors to Prevent Community-Acquired Ulcers in Veterans with SCI. The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Author information

Authors and Affiliations

  1. Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA

    Chad M. Osteen, Autumn Smith, Brian Bartle, Reside L. Jacob, Frances Weaver, Sherri L. LaVela & Elizabeth Burkhart

  2. Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL, USA

    Frances Weaver

  3. Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Sherri L. LaVela

  4. Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, IL, USA

    Elizabeth Burkhart

Authors
  1. Chad M. Osteen
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  2. Autumn Smith
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  3. Brian Bartle
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  4. Reside L. Jacob
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  5. Frances Weaver
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  6. Sherri L. LaVela
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  7. Elizabeth Burkhart
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Contributions

CO conducted participant recruitment and data collection, assisted in the chart reviews, performed thematic coding, and was the primary manuscript author. AS was responsible for project management. She contributed to protocol development, participant recruitment, data collection, and assisted in the chart reviews. BB contributed to the analysis plan, and data extraction, curation and analysis. Contributed to the manuscript. RL contributed to data extraction, curation and analysis. Assisted with the data analysis plan. Contributed to the manuscript. FW provided feedback on the conducting of the study and contributed to the writing of the manuscript. SL provided feedback on the conducting of the study and contributed to the writing of the manuscript. EB was the primary investigator of the project and lead designing the protocol, study design, collaboration with the SCI clinic, and analysis plan. She oversaw data collection and chart reviews. She contributed to thematic coding and the writing of the manuscript.

Corresponding author

Correspondence to Chad M. Osteen.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

Approval for the study “Engaging Patients and Providers in Identifying and Addressing Modifiable Risk Factors to Prevent Community-Acquired Ulcers in Veterans with SCI” and data collection was received from the Edward Hines, Jr. VA Hospital’s Institutional Review Board (era commons # 1 I01 HX002329-01A2, VA HSR IIR 16-267). Informed consent was obtained from all participants. No published images were obtained. All methods were performed in accordance with relevant guidelines and regulations.

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Osteen, C.M., Smith, A., Bartle, B. et al. A root cause analysis of community-acquired pressure injuries in persons with spinal cord injuries. Spinal Cord Ser Cases 11, 11 (2025). https://doi.org/10.1038/s41394-025-00707-z

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