Quality improvement issues in healthcare focus on the care patients receive and the outcomes they achieve. Nurses play a major advocacy role in ensuring safe, quality care for all patients. Additionally, nurses share responsibility for leading efforts to improve patient care in all settings (Berwick, 2002). One of the persistent problems plaguing hospitals and nursing homes is the development of new pressure sores in patients after admission. A pressure ulcer can be defined as a localized area of ​​necrotic tissue that may occur after soft tissue is compressed between a bony prominence and a surface for prolonged periods of time (Andrychuk, 1998). According to the Centers for Medicare and Medicaid, patients should never develop pressure ulcers while under the supervision of a medical facility because they are completely preventable (Berwick, 2002). The purpose of this article is to discuss the problems associated with pressure ulcers, review the progress made in improving this specific problem, and explain the Plan, Do, Study, Act cycle that I would use to improve pressure ulcer care. patients in this area.DiscussionProblem: Pressure UlcersReducing pressure ulcer prevalence rates is a national health care goal (Lahmann, Halfens, & Dassen, 2010). The development of pressure ulcers leads to increased costs for the medical establishment and delayed healing in affected patients (Thomas, 2001). Standards and guidelines developed for pressure ulcer prevention are not always followed by nursing staff. For example, nurses are expected to complete a comprehensive assessment of new patients within 24 hours in most acute care hospitals and nursing homes (Lahmann et al., 2010). A recent study on the causes of pressure sores...... middle of article ......quest.com/docview/195968886?accountid=14472Berwick, DM (2002). A user manual for the IOM “quality chasm” report. Health Affairs, 21(3), 80-90. Retrieved from http://search.proquest.com/docview/204628853?accountid=14472Institute for Healthcare Improvement. (2014). How to improve. Retrieved from https://www.ihi. org/resources/Pages/HowtoImprove Lahmann, NA, Halfens, RJG, & Dassen, T. (2010). Impact of prevention structures and processes on the prevalence of pressure ulcers in nursing homes and acute care hospitals. Journal of Assessment in Clinical Practice, 16(1), 50-56. doi:http://dx.doi.org/10.1111/j.1365-2753.2008.01113.xThomas, DR (2001). Problems and dilemmas in the prevention and treatment of pressure ulcers: a review. The Journals of Gerontology, 56A(6), M328-40. Retrieved from http://search. proquest.com/docview/208635333?accountid=14472