Adverse Patient Safety Events During the COVID-19 Epidemic

The coronavirus disease 2019 (COVID-19) epidemic has exposed vulnerabilities within the U.S. healthcare system and globally. This study reviewed COVID-related high-harm patient safety events in the Veterans Health Administration to further our knowledge of the effects of the COVID-19 pandemic on patient safety.MethodsA retrospective descriptive analysis of patient safety events related to COVID-19 was performed on data that were submitted in the Joint Patient Safety Event Reporting System and Root Cause Analysis databases to the VHA National Center for Patient Safety from March 2020 to February 2021. Events were coded for type of event, location, and cause of event.ResultsDelays in care and staff/patients exposed to COVID-19 were the most common types of patient safety events, followed by COVID-19-positive patients eloping, laboratory processing errors, and one wrong procedure. The most frequently cited locations where events took place were emergency departments, medical units, community living centers, and intensive care units. Confusion over procedures, care not provided because of COVID-19, and failure to identify COVID-positive patient before they exposed others to COVID were the most common causes for patient safety events.DiscussionOur results are similar to other studies of patient safety during the first year of the COVID-19 pandemic. Based on these results, we recommend the following: (1) focus on patient safety culture, leadership, and governance; (2) proactively develop competency checklists, cognitive aids, and other tools for healthcare staff who are working in new or unfamiliar clinical settings; (3) augment or enhance communication efforts with patient safety huddles or briefings at all levels within a healthcare organization to proactively uncover risk and mitigate fear by explaining changes in policies and procedures; and (4) maximize the use of quality and patient safety experts who are knowledgeable in system and human factor theories as well as change management to assist in redesigning clinical workflows and processes.

Automated summary

This study reviewed COVID-related high-harm patient safety events in the Veterans Health Administration to further understand the impact of the COVID-19 pandemic on patient safety. Delays in care, staff/patients exposed to COVID-19, COVID-19-positive patients eloping, laboratory processing errors, and wrong procedures were common types of patient safety events. The study suggests focusing on patient safety culture, leadership, and governance, developing tools for healthcare staff in new or unfamiliar clinical settings, enhancing communication efforts, and involving quality and patient safety experts in redesigning workflows and processes.