Epidural analgesia is an effective strategy in acute postoperative pain management; however not without the potential for adverse consequence. Increasing prevalence in hospital-acquired heel pressure ulcers are of growing concern in acute care facilities. Within the author's hospital, two surgical patients prescribed epidural analgesia displayed signs of heel pressure despite adherence to local pressure prevention guidelines. A research project commenced aimed at preventing recurrence. Data generated from our study identified that both patients' innate characteristics and routine hospital practices were linked to heel injuries in these patients. Multiple Comorbidity, hypotension, and anti-embolic devices were just some of the factors found to be influential. These findings, and the suggested recommendations, are anticipated to assist us as safe clinicians continually striving to improve nursing practice in risk assessment and heel pressure preventive strategies our study found essential for this patient cohort.