Preventing pressure ulcers has been a nursing concern for many years. In fact, Florence Nightingale in 1859 wrote, “If he has a bedsore, it’s generally not the fault of the disease, but of the nursing”4 (p. 8). Others view pressure ulcers as a “visible mark of caregiver sin”5 (p. 726) associated with poor or nonexistent nursing care.6 Many clinicians believe that pressure ulcer development is not simply the fault of the nursing care, but rather a failure of the entire heath care system7—hence, a breakdown in the cooperation and skill of the entire health care team (nurses, physicians, physical therapists, dietitians, etc.). From: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 12 Pressure Ulcers: A Patient Safety Issue Courtney H. Lyder; Elizabeth A. Ayello.