The exact incidence and prevalence of pressure ulcers remain unclear. Data from the National Pressure Ulcer Advisory Panel (NPUAP) in the United States [19] indicate that the incidence varies widely, from 0.4 to 38 % in acute care, 2.2–23.9 % in long-term care, and 0–17 % in home care. Prevalence rates show the same variability: 10–18 % in acute care, 2.3–28 % in long-term care, and 0–29 % in home care. Therefore, the incidence of pressure ulcers is high, especially among certain high-risk groups of patients. These groups include elderly patients admitted to a hospital for femoral fractures (66 %) and critical care patients (33 %); in a study of quadriplegic patients, the prevalence was 60 % [16]. In spinal cord injury (SCI) patients, the pressure ulcer prevalence rate ranged from 8 % in the first year following the onset of spinal cord injury to 33 % for community resident individuals with SCI [17].

Mawson et al. (1988) reported that 32–40 % of all individuals admitted to special SCI units in the United States would develop pressure ulcer(s) during their initial hospital admission period [20]. Yarkony and Heinemann in 1995 followed up on 4,065 individuals with SCI, of whom 2,971 developed pressure ulcers in the following percentages: 15 % at their first annual examination, 20 % at year 5 post injury, and 5.23 % at year 20 post injury [21].

Recurrence in spinal cord injury individuals remains high and is related to many factors. Niazi et al. in 1997 conducted a retrospective, case-controlled study on recurrence of pressure ulcers in a population of 176 veterans with SCI. They found that there was a 35 % recurrence rate regardless of whether the treatment was surgical or medical. Smoking, diabetes, and cardiovascular disease were associated with the highest rate of recurrences [22]. Clark et al. (2006) reported that daily lifestyle of the SCI patient and its relation to development of pressure ulcers can be described through various models that vary in complexity, depending on whether they incorporate individualization and interrelations among modeled elements [23].

The cost of managing pressure ulcers has increased dramatically in hospitals and in the community due to the overall increase in healthcare costs worldwide. The impact of pressure ulcers is significant in terms of both financial and nonmonetary costs. In 1999, Beckrich and Aronovich [24] reported that 1.6 million pressure ulcers developed in hospitals in the United States annually, with an estimated cost of $2.2 to $3.6 billion. Pompeo [25] showed the impact of wound burdens (defined as pressure ulcer stage, wound size, and number of wounds) on the cost of care at long-term acute care facilities; as expected, the higher the wound burden, the greater the cost of care. The nonmonetary costs, often described as a hidden cost of pressure ulcers, include the emotional and physical impact on patients and their families. Braun et al. (1992) [40] reported that the cost to heal complex pressure ulcers was $100,000; less serious pressure ulcers cost $20,000 to $30,000 to heal (National Pressure Ulcer Advisory Panel 1989, U.S. Department of Health and Human Services 1990) [26, 16].

The medico-legal implications of pressure ulcer development are an urgent issue all worldwide. Pressure ulcers are viewed as a quality indicator of care. Hence, the development of pressure ulcers can constitute a failure in the healthcare system. In the United States, federal health agencies regard pressure ulcers as a surrogate for how well the healthcare team is functioning in monitoring the quality of care for the patient.

The growing demand for accountability among healthcare clinicians for more effective prevention and management of ulcers has led to an explosion of national guidelines on pressure ulcers. In the European countries, guidelines have been developed that are similar to those issued by the U.S. Agency for Health Care Policy and Research for Pressure Ulcer Prevention [27].

The increasing recognition of pressure ulcer development as a marker for quality of care has led to a greater number of pressure ulcer litigations against clinicians and their employers. The public has been made aware through the media like television and Internet that pressure ulcers can be prevented and treated effectively. The development of pressure ulcers is considered to be the result of negligence by the healthcare provider. Pressure ulcers can cause sepsis and even death in certain groups of patients, in addition to causing changes in patients’ quality of life. A number of lawsuits have been brought against hospitals, nursing homes, physicians, and even plastic surgeons. If greater attention were paid to preventing development of pressure ulcers and to enforcing some basic rules of prevention, there would be fewer of these litigations.

In the United States, Bennett et al., in 1981, reported on the increase in medical malpractice related to patient pressure ulcer development [28]. Absence of good documentation in patients’ medical charts concerning preventive measures taken in action or treatment make it easy for a plaintiff’s attorney to prove the lack of care that caused the development of pressure ulcer(s) in the patient. When there is a national guideline on how to prevent and treat pressure ulcers, the expert witness in these litigation cases defends the care according to those guidelines. In the United States, the federal government and each state set rules and regulations, including monetary penalties, for nursing home compliance for patients who develop stage III or IV pressure ulcers [29].