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. 2025 Apr 22;11(1):11.
doi: 10.1038/s41394-025-00707-z.

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

Chad M Osteen  1 , Autumn Smith  2 , Brian Bartle  2 , Reside L Jacob  2 , Frances Weaver  2   3 , Sherri L LaVela  2   4 , Elizabeth Burkhart  2   5
Affiliations

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

Chad M Osteen et al. Spinal Cord Ser Cases. .

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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Conflict of interest statement

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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