Patient Safety in Ulcer Management: Healthcare Professionals’ Experiences of Systemic Challenges Across Primary and Secondary Healthcare Settings

Background/Objectives: Ulcers affect people of all ages worldwide, and hard-to-heal ulcers require extensive management. Patients with hard-to-heal ulcers often receive care across multiple healthcare settings, which may increase risks to patient safety. There is limited knowledge of how healthcare professionals maintain patient safety when patients with hard-to-heal ulcers transition across healthcare settings. The aim of this study was to explore healthcare professionals’ experiences of patient safety in ulcer management in primary and secondary healthcare settings. Methods: A qualitative research design was adopted. Fifteen semi-structured interviews were conducted, transcribed, and analysed, using qualitative content analysis. The healthcare professionals represented various professional roles and worked in either primary or secondary care. Results: The study resulted in one overarching theme and three categories. Given the complexity and demands of ulcer management, healthcare professionals needed to ensure safe care. In an organisation with unclear structures, professionals felt compelled to safeguard and develop their expertise themselves. Limited formal training in ulcer management, along with a reliance on a few more experienced colleagues, contributed to a sense of inadequacy among healthcare professionals. In ulcer management, professionals acted in the patient’s best interests, helping address gaps in patient safety. Conclusions: The findings of the present study illustrated how healthcare professionals are largely left alone in ulcer management. Challenges due to organisational structures posed patient safety risks, which were, to a large extent, mitigated by the professionals’ dedication to patient care. This study highlights the need for stronger structural support to complement individual competence in promoting safe and effective ulcer management. Patient safety should not depend solely on individual professionals, but on structured, organisation-level guidelines.