There is an ongoing debate, regarding the topic of the unavoidable versus the avoidable pressure injury as evidenced by a growing body of literature. The National Pressure Injury Advisory Panel (NPIAP) has conducted two consensus conferences on this topic, the first in 2010 and the second in 2014. In the publication of the proceedings from the 2014 event, it was noted that the threshold for consensus was set at 80%. A total of 15 Consensus Statements were generated, and the final consensus statement was ‘Unavoidable pressure injuries do occur’ with an affirmative response rate of 95% by organizational representatives and 100% by the audience. Stakeholders from various care settings, whose clinical practice focused on pressure injury prevention and treatment, were sourced, and there were 25 interprofessional organizational representatives present. I had the opportunity to attend both of these events and participate in the consensus process. This issue, along with the associated body of literature, is relevant to a recent case review that I am conducting.

According to a position paper by the WOCN Society, an unavoidable pressure injury can develop even if the provider evaluated the individual’s clinical condition and pressure injury risk factors, defined and implemented interventions consistent with individual needs, goals, and recognized standards of practice, monitored and evaluated the impact of the interventions, and revised the approaches as appropriate (WOCN Society, 2017). In some cases, pressure injuries are unavoidable due to the overwhelmingly high magnitude and severity of risk or when preventive measures are either contraindicated or inadequate given the magnitude and severity of risk (Edsburg et al., 2014).

Both intrinsic and extrinsic risk factors can impact the determination of unavoidability. Intrinsic factors include impaired tissue oxygenation/cardiopulmonary dysfunction, hypovolemia, anasarca, sensory impairment, multiorgan dysfunction syndrome, critically ill/injured status, and body habitus. Extrinsic factors include immobility, head-of-bed elevation, nutrition, and facility length of stay. This brief list only scratches the surface, and each factor deserves its own thorough investigation. Despite the delivery of nursing care based on best practices and the involvement of a comprehensive interprofessional team, pressure injuries can still occur, leading to significant legal and regulatory implications.

According to CMS, “Unavoidable” means that the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as

I highly recommend that you seek out and review the aforementioned papers if you are analyzing cases involving liability associated with pressure injuries. If you would like to continue this conversation, please provide a comment, and I would be more than happy to engage in an ongoing dialogue.


Edsberg, Laura E., Diane Langemo, Mona Mylene Baharestani, Mary Ellen Posthauer, and Margaret Goldberg. “Unavoidable Pressure Injury: State of the Science and Consensus Outcomes.” Journal of Wound, Ostomy & Continence Nursing 41, no. 4 (July 2014): 313–34.

Schmitt et al. “WOCN Society Position Paper Avoidable Versus Unavoidable Pressure Ulcers/Injuries.” Journal of Wound Ostomy & Continence Nursing 44, no.5 (September/October 2017): 458-468.

42CFR 483.25.c F314 Definitions: Avoidable/Unavoidable Pressure Ulcers