Potential risks and medical errors can be minimized in medical field by considering various parameters that monitor, judge client’s safety and ensure quality care to the patients. Patient safety and quality care both are indistinguishable terms which play significant role in the context of health care system. Australian Commission for Safety and Quality in Health Care defines safety “as the degree to which potential risk and unintended results are avoided or minimized” . Patient safety practices have been defined by Journal of Medical Association as “those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions” . The term quality is a multi-dimensional concept that can be defined in various ways. Simply, quality care is a benchmark for all health care professionals. It is providing right care to the right client with minimal risks and giving the best service In depth, quality health care refers providing health care in such a manner that leads to achieving the targeted goal . According to Institute of Medicine (IOM), quality care is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” It has covered six main aims which emphasizes on the overall health care system for providing better qualitative care. These aims are safety, patient centeredness, effectiveness, efficiency, timeliness and equity . Agency for Healthcare Research & Quality (AHRQ) formulated quality indicators (QIs) in early 1990s which were built on project called Healthcare Cost and Utilization Project (HCUP), a uniform national database of hospital inpatient data that comprises total 33 indicators that covers aspects of possible complications and negative consequences after surgery, childbirth and inpatient mortality . QIs are measurement tools that measure various processes of health care, structure of organization, and the outcomes of high quality care of clients. Least acceptable standard of practice are specified through such tools. It helps to evaluate the effectiveness of given treatment which are evident to clients, hospital staffs, funders and managers. QIs are associated with judging quality care that has been delivered and usually based on systematic, rigorous and transparent approach for ensuring the framework of high quality measures in health care setting. Patient safety indicators are a set of measures that are designed to identify the potential risk and hazards including the verification of possible safety events in hospital settings for improving the quality care and for effective health outcomes. Based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), Agency for Healthcare Research and Quality (AHRQ) has developed these tools. Patient safety indicators (PSIs) have huge impact in health care system due to its accessibility, availability, affordability, screening capacity, cost effectiveness, huge patient coverage, and interchangeability over time for assessing patient safety scenarios and needs . It is beneficial for assessing potential risks, complications, prevalence and incidence of adverse effects, using hospital records of typical discharge and administrative data . Pressure ulcers are serious health care issue which is known as bedsore or decubitus ulcer or sometimes pressure injuries and may be the result of unrelieved pressure over bony prominences exposed to compressing surfaces. It causes lesion in soft tissue and ultimately damages the underlying tissue. The prevalence of pressure ulcer is a significant marker for assessing quality of health care . National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) has further described pressure sore as “localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction”. It lead the patient to suffer more with painful experience, embarrassment, giving a sense of failure and increased workload for nurses, hospital staff members and resulting in longer duration of stay in hospital adding significant health care cost. The prevalence rates is 10-17% in acute care, 0-29% in home care and 2.3-23.9% in long-term care facilities . The mortality and morbidity rates are also found to be higher, especially in the ICU patients due to the prolonged stay that might provoke in deterioration of pressure ulcer . In general, between periods of 2012 to 2014, excluding stage I, 11% of ICU patients experienced unusual experience of hospital acquired pressure ulcer while only 3% of non-intensive care clients were affected by pressure ulcer. It demonstrated the higher risk among the ICU patients when compared with the other non-intensive care patients. ICU patients were 3.8 times more vulnerable than the other patients. Most common site was found to be coccyx/sacrum in 22% ICU patients and 35% in non-intensive care clients. But mucosal pressure injury was relatively higher in ICU patients with 22% than those with only 2% in other clients. On the other hand, findings showed the higher prevalence rate was in stage II Hospital acquired pressure injury (HAPI), which was 53% in ICU patients and 63% in other non-intensive clients . Due to such results, prevention and management of pressure ulcer has been considered as a key quality target by National Health Service (NHS) for minimizing potential risks, and prevention of pressure ulcer in later period (Department of Health 2012). Around more than 95% of pressure ulcers develop on the lower half portion of human body especially pelvic girdle as being the heaviest part. Other possible risk areas are sacrum, occiput, calcaneus, scapula, chin, elbow, femur, greater trochanter of femur, scapula, ischial tuberosity, iliac crest and lateral malleolus . There have been division system for various stages of pressure ulcer which was earlier developed by Shea in 1975 that was later modified in 1989 and NPUAP further refined it again and is being used most commonly today. It has divided pressure ulcer staging in 4 groups. Stage 1, where skin tone and color may change like red, purple or blue hues in skin when comparing to other body parts. Stage 2 involves slight skin loss including the dermis or epidermis layer, characterized by superficial ulcer termed as blister or an abrasion. Stage 3 is associated with full thickness loss of skin along with injury to subcutaneous tissue which may extend further but does not involve underlying fascia. Stage 4 usually involves extreme destruction of tissue, muscle layer, its adjacent parts and structures, bone and extensive tissue necrosis . Simply, a pressure ulcer risk assessment scale is used to detect the high risk patients who are more vulnerable. Risk factors include bed ridden, mal-nourished or patient with impaired nutritional status, and long term hospital stay, especially in ICU patients , skinny and old age people, patients with spinal cord injury, limited mobility and incontinence. Especially Barden Scale and Norton scale are widely used in hospital settings for assessing risk. These are used in daily activity sheet and admission forms to identify high risk groups and to provide appropriate treatment to the suffered patients. Nurses and other health members play a major role for prevention, control, evaluation, monitoring and management of pressure sore in hospital setting. Patients need special and continuous supervision for preventing further complications and skin breakdown, to avoid possible infection and for progression of wound healing . Barden scale was first initiated by Barbara Braden and Nancy Bergstrom in 1987. This scale detect and rate the severity of pressure ulcer on the basis of five sub scales like sensory perception, mobility, activity, moisture, and nutrition. In this scoring tool, higher the score, there is a less chance of risk for developing pressure sore and high chance of getting affected, if score is low. In this, score ranges from 1-4. Score 1 is poor and 4 is normal. According to original Barden scale, 22-25 score is considered as mild risk, 17-21 is termed as moderate risk and less or equal to 16 is considered as high risk. Most of the scientific journals has rated it best, in terms of sensitivity. It is quite effective for nursing staffs and health team members if used appropriately Table: Barden Scale for assessing risk for pressure ulcer 1 2 3 4 1.Sensory Perception Completely limited Very limited Slightly limited No impairment 2.Moisture Constantly moist Very moist Occasionally moist Rarely moist 3.Activity Bedfast Chair fast Walks occasionally Walks frequently 4.Mobility Completely immobile Very limited Slightly limited No limitation 5.Nutrition Very poor Probably inadequate Adequate Excellent 6. Friction and Shear Problem Potential problem No apparent problem Score interpretation for developing pressure sore ≤ 11 : Severe risk for developing pressure sore 12-14 : Moderate risk of getting pressure sore 15-18: Mild risk for developing pressure sore The pressure sore has direct impact on patient’s quality of life along with other family members and care givers. They might feel depressed, unmanaged, insecure, feeling of worthlessness and burdened, socially and physically isolated that ultimately lead to increased negativity towards life. It gives the sense of losing independency, along with other bad health issues like infection, poor hygiene, ignorance, limited activities of daily living, weight loss, increased stress level, delayed wound healing and irritability and causing impact on health-related quality of life (HRQL). The National Institute of Clinical Excellence (NICE) draws attention towards prevention of pressure ulcer and prioritizes it as top most issue. An assessment tool was developed by EPUAP and NPUAP by considering international and national guidelines which were based on identification of pressure ulcer prevention and its importance, relevant for proper documentation. Annette Richardson and Isabel Barrow, in Nursing Critical Care used a locally formulated assessment tool called ‘CALCULATE’ which is not a definitive guide for critically ill clients but may provide significant role in developing more advanced and better tools in future. Moreover, it helps nursing staff to follow guidelines given by NICE and is very advantageous in proper documentation of pressure ulcer risk assessment . (CALCULATE) 7 Point Pressure ulcer assessment tool Too unstable to turn automatically into high risk group Impaired circulation includes history of IV inotropes, diabetes, vascular disease Dialysis IHD or CVVHD Mechanical ventilation any type of ventilation including CPAP long surgery length of surgery more than four hours in last twenty four hours low protein low protein or albumin serum (albumin below 35g/l) level or in poor nutritional state fecal incontinence diarrhea NPUAP in collaboration with EPUAP developed new guidelines in 2009 that provides various recommendations based on significant evidence and findings concerned with major aspects of treatment and prevention of pressure ulcer, including assessment of skin integrity, risk assessment, use of support surfaces, repositioning and nutrition . On the basis of different guidelines set by hospital settings, nurses have a huge role to play in promoting health of patients with pressure ulcer . Identifying risk factors: These refer to excessive moisture, low level of nutrition, friction, limited activity, skinny and old age and prolonged stay in hospital. Prevention: Controlling friction, decreasing pressure duration and using pressure relieving devices like air pillow and mattresses, use of cushion in between thighs and the two skin surfaces which are likely to cause friction, using other supportive devices, in more bony prominent areas, to avoid friction. Repositioning and ambulation: Position should be changed every 2-4 hourly. Encouraging ambulation to the patients who are at stage I and are able to do so increases the mobility and enhances blood circulation. Skin Care: Assessing the condition and tolerance level of skin, Cleansing and applying lotions, and topical agents to moisturize the skin that prevents skin from getting dry. Back care relieves pressure in the high risk area. Wound care: It provides valuable information regarding prognosis and healing of wound, along with inspection for possible infections and further complications. Counselling to patient and family members: It’s really an unusual experience for both the family and patient party to experience such medical crisis. Reliable, updated information related to prevention and management is required in counselling. Protecting the skin from irritants: Urinary and fecal incontinence produces chemical irritation and spreads micro-organisms that increase the risk of infection and skin irritation. Improving nutrition: Dietician consultation is required to enhance the nutritional status of the body to promote the pressure tolerance level according to body weight. Providing support: Physical, emotional and psychological support is a major part in clinical setting. Conclusion: Nurses and other healthcare members are the vital part in assessing, preventing, monitoring and treating patients with pressure ulcer. Patient safety and quality measure guidelines if followed appropriately along with effective and advanced training, it surely increases the possibility of achieving our desired health outcomes. Nurses are the backbone of the health care organizations at various levels who are accountable and responsible even in the later stage or end stage life of patients. Sufficient staff members, appropriate risk assessment tools and continuous supervision combining with patient centered care minimizes the risk of pressure sore and management. Education and training also helps in preventing development of pressure sores.