CLN-SOP-004: Pressure injury risk assessment and prevention

Standards › Standard 1 › Standard operating procedures (SOPs)

Standard operating procedure (SOP) · CLN-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 1.6

At a glance

Every patient is assessed for pressure injury risk on admission.
The assessment is repeated at the set interval and after any change.
Each at-risk patient has a written prevention plan.
Prevention is started before any injury develops.
Stop and get help straight away if: an at-risk patient has no prevention plan, or a pressure injury develops with no plan in place.

1. Purpose

To prevent pressure injuries, which develop in hours in a patient who cannot move (1.6).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

Pressure injuries develop in hours on a patient who cannot move, and they are among the most preventable harms in hospital. Assessing risk on admission and repeating it, with a plan, prevents them.

5. Responsibilities

Role	Responsibility	Competence
Ward nurse	Assesses and sets the plan	Nurse
Tissue viability lead	Advises on surfaces and wounds	Nurse specialist

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Assess.

Assess each patient on admission and at the set interval (CLN-FRM-006).

Key point: Risk is re-checked.

Step 2. Plan.

For each at-risk patient, set the repositioning schedule and the surface.
Record the plan.

Key point: A written plan.

Step 3. Check the skin.

Check the skin at each repositioning and report any change the same shift.

Key point: Early change, early action.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Patients assessed on admission	100%	Monthly	Ward manager	Escalate to clinical director
At-risk patients with a written plan	100%	Monthly	Tissue viability lead	Escalate to clinical director

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
CLN-FRM-006	Pressure injury risk and prevention record	Record

17. Evidence

Reference	Note
E-009	Based on the international pressure injury prevention guideline (EPUAP, NPIAP and PPPIA, 2019).
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

E-learning for this document

Emergency Preparedness and Fire Safety (T-10)
Basic Fire Response & Extinguisher Use (FIRE-01)
Safety & Emergency Preparedness (H-05)
Clinical & Medical Care in Long-Term Care (LTC-04)
Care & Treatment: Clinical Standards for Accreditation (H-04)

References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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