Unit 38: “4 Eyes in 4 Hours” – A Model for Successful HAPI Reduction

Unit 38 has demonstrated how consistent, disciplined practice can transform patient outcomes by adopting the “4 Eyes in 4 Hours” standard for every admission and transfer. By requiring that all patients receive a two-person skin assessment within four hours of arrival or change in level of care, the unit created a culture of accountability, teamwork, and early detection. This standardized expectation ensured that no patient transitioned between care settings without a complete and verified skin check, minimizing the opportunity for unseen breakdown. As a result, Unit 38 not only improved compliance with the assessment process but also advanced its pressure-injury prevention goals—specifically targeting a 10% reduction in HAPIs, moving from 2.030 per 1,000 patient days to 1.827 per 1,000 patient days. The unit’s structured workflow, reliable documentation, and proactive intervention have made “4 Eyes in 4 Hours” a cornerstone of their patient-safety success and a model for other teams seeking measurable improvement.

The Evidence-Based Value of the Four-Eyes Skin Assessment: A Proven Approach to Preventing Hospital-Acquired Pressure Injuries

Hospital-acquired pressure injuries (HAPIs) remain a major patient-safety concern across all care settings. The financial, clinical, and emotional impacts of preventable skin breakdown are significant, affecting patient outcomes, length of stay, quality of life, and institutional performance benchmarks. Among the most effective and research-supported strategies for reducing HAPI incidence is the Four-Eyes Skin Assessment, a two-person skin evaluation conducted at key transition points in care.

A 2024 study by Lass, Warg, & Dagestad demonstrated that implementing a structured Four-Eyes Assessment program dramatically reduced HAPI rates, identifying early skin changes that might otherwise be missed and improving the timeliness of interventions. Their work confirms what frontline nurses already know: two sets of trained eyes increase detection, improve accuracy, and save patients from preventable harm.

This article outlines the evidence behind the practice and presents a clear, practical breakdown—based on your Job Instruction Breakdown Sheet (JIBS)—for implementing the Four-Eyes Assessment reliably and consistently.

Why a Two-Person Skin Assessment Matters

Research has repeatedly shown that solo assessments miss early skin breakdown, especially in high-risk anatomical areas or in patients with complex medical devices. The Four-Eyes Assessment:

• Improves accuracy through cross-verification by two staff members
• Reduces variation in wound staging, documentation, and identification
• Ensures safety during patient turning and device removal
• Supports early intervention, preventing progression of redness or compromised skin
• Strengthens accountability and communication between caregivers

Lass et al. (2024) reported that this teamwork-based model significantly reduces the incidence of HAPIs, confirming its effectiveness as a best practice in nursing care.

The Four-Eyes Skin Assessment: A Step-by-Step Evidence-Based Guide

1. Preparation and Staffing: A Four-Eyes Assessment requires two trained staff members (RN, LPN partner, CNA, or NST). 
Note: An LPN cannot complete the initial skin assessment independently.

Key Actions

• Identify the second licensed professional.
• Ensure access to a work phone and Rover.

Why It Matters 
Two trained caregivers ensure thorough inspection, safe patient handling, and the ability to manage devices appropriately.

2. Introduce and Educate the Patient: Clear communication reduces anxiety and promotes cooperation.

Key Actions

• Introduce the second staff member and explain the assessment steps.
• Reassure the patient that wound images are confidential and stored securely in the EHR.
• Encourage independent movement when possible.
• Complete at admission/transfer (within 4 hours of unit transfer or 8 hours of ED arrival per policy).

Why It Matters 
Patient education builds trust, maintains privacy, and improves the accuracy of the examination.

3. Conduct a Systematic Head-to-Toe Assessment: The Four-Eyes assessment follows a logical, evidence-based sequence to avoid missed areas.

• Head and Neck: Inspect scalp, ears, nares, lips, neck; skin beneath oxygen tubing, NG tubes, masks
• Upper Extremities: Inspect armpits, elbows; sites under IVs, midlines, PICC lines, BP cuffs, oximeters, braces, and tape
• Chest and Trunk: Inspect under breasts and abdominal folds, skin beneath chest tubes, ports, gastric tubes, binders, braces
• Lower Extremities: Inspect hips, legs, feet, heels, skin under SCDs, TED hose, boots, braces, heel protectors
• Posterior Torso: turn patient safely using a two-person turn if needed; inspect spine, shoulder blades, back of scalp, neck, torso
• Posterior Legs: inspect backs of legs and under braces
• Coccyx and Buttocks: examine sacrum, coccyx, buttocks, assess rectal tubes and Mepilex dressings, apply sacral patch for redness as appropriate
• Groin: turn patient back; inspect under Foley, StatLock, PureWick devices

Why It Matters 
A structured sequence prevents missed areas—especially bony prominences and device-related pressure points that research identifies as high-risk sites.

4. Documentation and Wound Imaging in Rover: High-quality documentation ensures accurate tracking and supports early intervention.

Why It Matters 
Clear photo documentation enhances continuity of care and ensures accurate staging.

5. Consults and Risk Assessment

• If skin breakdown is present
• Primary nurse places a wound care consult
• Provider is notified
• Complete Braden Scale assessment
• Nutrition consult ordered if indicated

Why It Matters 
Early consults are directly associated with better healing outcomes and reduced complication rates.

6. Interventions and Patient Education: The two-person team agrees on evidence-based interventions, such as:

• Sacral patches
• EHOB heel protectors
• Bed pumps
• Foam borders for heels, elbows, bony prominences
• Barrier cream
• Positioning wedges
• Foam Border Labeling
• “T” (Treatment) → for Stage 1 pressure injury, DTPI, or existing wound orders
• “P” (Prevention) → for bony prominences or redness
• Treatment foam borders: good for 24 hrs
• Prevention borders: good for 3–7 days

Why It Matters 
Standardized intervention labeling reduces confusion and improves continuity of care across shifts.

The Evidence Is Clear: Four Eyes Save Skin

The structured Four-Eyes Skin Assessment is one of the most effective strategies for preventing hospital-acquired pressure injuries. Evidence shows that:

• Pressure injuries decline significantly when hospitals adopt a mandatory two-person assessment model.
• Early detection prevents worsening conditions and reduces cost and complications.
• Consistent documentation and imaging strengthen communication and continuity of care.

As Lass, Warg, & Dagestad (2024) demonstrate, a well-implemented Four-Eyes program can eliminate HAPIs in some settings—an outcome that has profound implications for patient health and organizational performance.

Conclusion

The Four-Eyes Skin Assessment is more than a policy requirement—it is an evidence-based, patient-centered practice that saves lives, improves outcomes, and strengthens nursing teamwork. When performed consistently using a structured process, it ensures:

• Thorough skin evaluation
• Early identification of risk
• Accurate documentation
• Timely interventions
• Safe patient handling
• Better clinical outcomes

By continuing to train staff with tools like the Job Instruction Breakdown Sheet (JIBS) and reinforcing the evidence behind the practice, healthcare teams can maintain the highest standards of patient safety and quality care.