A pressure ulcer (PU) is defined as localised damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear. Despite the fact that pressure ulcers have received a lot of attention recently in hospitals and long-term care homes, they still form a major issue. The ErasmusMC is one of the hospitals with concerns regarding pressure ulcerations. Currently, there is a need to know why the implementation of measures for the improvement of preventing pressure ulcers resulted in disappointing results within the hospital. Within a literature review, it was found that the concept of systems thinking and the application of this concept is lacking in the selected studies. Therefore, the research question of this thesis was: Why are the current measures for the prevention of pressure ulcers not working as expected and intended within the ErasmusMC hospital?

A case study approach with a single-case (holistic) design was chosen. From the concept of systems thinking (the dynamic interaction, synchronisation, and integration of people, processes, and technology), the multi-level perspective of Geels was applied to this case study. With the use of the six common sources of Yin, 22 recorded and summarised semi-structured interviews, 4 informal interviews, several observational moments whilst accompanying operational staff or participating in meetings, and countless informal conversations were collected. Furthermore, PowerPoint presentations, documents, and dashboard results of the ‘prevalentiemeting’ within the ErasmusMC were collected.

When applying the dynamic multi-level perspective on system innovations to the situation of preventing pressure ulcers within the ErasmusMC, it was found that the landscape developments represented the urgency of the policymakers of the hospital to lower the occurrence of pressure ulcers, the technological niches were the measures (or system innovations) created for preventing pressure ulcers, and the socio-technical regime could be described as the socio-technical system for preventing pressure ulcers within the ErasmusMC. Combining the hypothesis of the multi-level perspective and the findings of the theoretical reasons within the literature review, it was stated that a nested hierarchy (where regimes are embedded within landscapes and niches within regimes) was missing. The analysis of the collected data resulted in the practical socio-technical system of preventing pressure ulcer within the ErasmusMC, where the 10 system elements were filled in with overarching themes found within the qualitative data. Next to this, it was found that the system elements of the socio-technical were interconnected and these interconnections could be interpreted as the key leverage points for building resilience within the practical system. The key leverage points found within the interconnections of the practical socio-technical system for preventing pressure ulcers within the ErasmusMC are the following: communication, implementation, opinions of prevention measures, policy steps, doubts about measures, and responsibility.

By using the mutli-level perspective theory of Geels and applying it to a healthcare setting, this thesis showed why the current measures for preventing pressure ulcers are not working as expected and intended within the ErasmusMC. This research made a contribution to the generic actor-related patterns found within the dynamic multi-level perspective on system innovations by introducing the information related patterns. It is shown that this new pattern can be described by the crucial role of information and the flow of information within an organisation for the accelerations and slowing down in diffusion and breakthrough of new technologies.