A prospective observational study from a level III NICU determined the incidence of pressure ulcers in NICU patients. Designated nursing staff (skin champions) examined the skin of all NICU patients from head to toe on admission and then once in two weeks until discharge. Ulcers were assigned a severity stage that ranged from stage I (non-blanchable skin erythema) to stage IV (full thickness tissue loss with exposed bone, tendon or muscle). Out of 741 neonates monitored, 28 developed one or more pressure ulcers. There were 49 pressure ulcers among these 28 neonates, with an overall rate of 1.5 per 1000 patient days. The rate in preterm infants was 1 per 1000 days, and the rate in full-term infants was 2.7 per 1000 patient days. The majority of ulcers were of stage II, and most (80%) were from pressure from medical devices (many were from ECMO cannulas).