The debate surrounding avoidable versus unavoidable pressure injuries emerged in the 1990s when the National Pressure Ulcer Advisory Panel (NPUAP) (now the National Pressure Injury Advisory Panel (NPIAP) proposed the concept of “avoidable” pressure injuries. This concept challenged the traditional view that all pressure injuries were unavoidable and instead suggested that some pressure injuries could be prevented through appropriate nursing care and interventions. The recognition that not all pressure injuries are able to be prevented, certainly has impacted the manner in which legal wound care cases are addressed.

The NPIAP defined an avoidable pressure injury as “a pressure injury that develops from inadequate preventive interventions,” while an unavoidable pressure injury was defined as “a pressure injury that occurs despite appropriate preventive interventions” (Black et al., 2011). The introduction of the concept of avoidable pressure injuries caused significant debate among healthcare professionals and researchers.

Some critics argued that the concept of avoidable pressure injuries was unfair to healthcare professionals, as it placed blame on them for pressure injuries that were beyond their control. Others argued that the concept was necessary to improve the quality of nursing care and to promote accountability in healthcare.

To address the controversy surrounding the concept of avoidable pressure injuries, the NPIAP organized a consensus conference in 2008. I can still remember the impression that this conference had on myself and my colleagues, as we participated in a vigorous debate. The conference brought together experts in the field of pressure injury prevention and management to develop a consensus definition of avoidable and unavoidable pressure injuries and to identify best practices for prevention and management.

The conference resulted in the consensus statement, which defined avoidable pressure injuries as “pressure injuries that develop as a result of failure to implement or appropriately modify interventions consistent with standards of care,” and unavoidable pressure injuries as “pressure injuries that occur despite appropriate prevention efforts.”

The consensus statement also identified a range of factors that can contribute to the development of avoidable pressure injuries, including inadequate assessment and documentation, inadequate pressure injury prevention interventions, inadequate nutrition and hydration, and inadequate staff education and training.

Differentiating and defining the concept of avoidable v. unavoidable, has a critical ramifications for legal cases associated with pressure injuries. The Legal Nurse Consultant (LNC) who is involved in the review of medical records for cases involving pressure injuries, has consensus evidence from the expert Panel to address the issue of avoidability in target patient populations, such as those who may be hemodynamically unstable, implementation of medical devices, or are nonadherent with prevention practices (Black et al., 2011).

Overall, the NPIAP consensus conference helped to clarify the concept of avoidable versus unavoidable pressure injuries and provided guidance on best practices for prevention and management. The concept of avoidable pressure injuries continues to be a topic of debate in the healthcare community, but the consensus statement remains a valuable resource for healthcare professionals working to prevent and manage pressure injuries.


Black J. et al. Pressure Ulcers: Avoidable or Unavoidable? Results of the National Pressure ulcer Advisory Panel Consensus Conference. Ostomy Wound Management. 2011; February, 24-37.

Cynthia Sylvia, legal nurse consultant, is a Certified Wound Care Nurse with 42 years of clinical expertise. With a Doctorate in Nursing and an MSc in Wound Healing, Cindy is a former VP of Clinical Affairs, an honorary lecturer at Cardiff University and a published author and international speaker.