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Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic

January 12, 2022 
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The COVID-19 pandemic necessitated drastic modifications to the way in which health services are delivered across care settings, in particular in hospital emergency departments and inpatient units. Never was this truer than during surge periods requiring changes in patient workflows and reallocation of resources as hospitals needed to isolate patients with known or suspected COVID-19 infection, and also experienced an increase in device use (e.g., ventilators, catheters) and strains on availability of personal protective equipment (PPE). Particularly in the earlier phases of the pandemic, there were notable patient safety concerns associated with factors such as disease exposure, timely diagnosis, and treatment access related to these pressures on the system. In addition, provider burnout was a critical issue.1

Patient Safety Challenges

While managing the disease outbreak and caring for COVID-19 patients have been of high priority, there has also been the ongoing question and concern for frontline staff, policymakers, and researchers of how the unique situational factors caused by the pandemic have impacted hospital adverse events. Throughout the field, research evaluating the impact of COVID-19 on the safety of care has revealed several areas of concern and potential root causes for increases in safety events in a number of areas outlined below. Patient safety concerns related to COVID-19 were also addressed in a recently published analysis of data voluntarily submitted by federally listed Patient Safety Organizations (PSOs) to the Patient Safety Organization Privacy Protection Center (PSOPPC).2 There is a perception that healthcare workforce shortages, including expertise understaffing, are exacerbating many of these safety concerns.3

Communication Challenges

Personal Protective Equipment (PPE) introduces potential patient safety challenges. First, wearing additional layers of PPE, particularly respiratory protection (e.g., facemasks, respirators), muffles sounds, prevents lip reading, and makes reading facial expressions challenging.4 As such, it creates the risk of miscommunication between providers as well as between providers and their patients.5 Second, PPE and isolation requirements can create delays in provider response to bedside alerts, either due to not hearing the alert when the patient is in isolation, or due to the time required to don the necessary PPE.6 There are also opportunities to improve communication during patient transfers to ensure proper use of PPE when interacting with patients and families.2

Pressure Injuries

The risk of pressure injuries of the skin and soft tissue has increased during the pandemic. Prone positioning for ventilated patients has been widely adopted for patients with COVID-19. While the prone position has led to better outcomes, it has also created a unique challenge for nursing staff when it comes to preventing pressure injuries. Not only is patient repositioning more challenging, but the continuous pressure points are very different from those that nurses typically encounter and manage. Additionally, the presence of ventilation devices creates additional points of pressure that increase the risk of pressure injury among COVID-19 patients.7


Among COVID-19 patients in particular, hospital data has indicated an increased risk of hospital-acquired infections during the pandemic. One study found that when comparing 12 months of data from just prior to the pandemic to six months of data during the pandemic, central line-associated bloodstream infection (CLABSI) rates increased 51% and the rate of infection was higher among hospitals with a higher percentage of COVID-19 admissions.8 Other studies have found that urinary catheter and central venous catheter use increased during the pandemic6,9 and that COVID-19 patients are at a higher risk of both CLABSI and catheter-associated urinary tract infection (CAUTI).7,10 This increased risk of infection may, in part, be due to increased device utilization and prolonged hospitalization of COVID-19 patients, but also to challenges in maintaining those devices (catheters, central lines, etc.), while trying to limit provider exposure and conserve PPE. Further, the need to place intravenous pumps in hallways and the use of patient prone positioning created variation in lines that necessitated changes to routine line maintenance.6

Sepsis Management

Another area impacted by surges in COVID-19 is sepsis management. COVID-19 and sepsis manifest similarly in patients,11 but require different treatment pathways. Notably, COVID-19 infection is not responsive to antibiotics or fluid resuscitation. Additionally, many COVID-19 patients develop sepsis, further complicating the treatment approach.12 For example, respiratory failure in patients with COVID-19 and sepsis requires them to be managed differently.13,14 Timely diagnosis and management of COVID-19 or sepsis, or the identification of sepsis among COVID-19 patients, increases the likelihood of survival.15 However, the COVID-19 pandemic has created hurdles for personnel in ensuring compliance with the widely utilized Severe Sepsis and Septic Shock: Management Bundle. Compliance with the bundle has been demonstrated to decrease inpatient mortality for patients with sepsis,16 but the need to confirm a COVID-19 diagnosis creates barriers that may delay the provision of care.

Innovation to Support Safety

In response to the unique challenges of the pandemic, particularly with regard to patient and disease management, government agencies, researchers, and professional associations have worked expeditiously to produce guidance to support healthcare personnel in preventing safety events. For example, the Centers for Disease Control and Prevention has produced guidance for optimizing PPE supplies. Harm-specific examples include the guidance developed by the Sepsis Alliance Institute, resources developed by the National Pressure Injury Advisory Panel, and recommendations developed by researchers on the prevention of pressure injuries, all of which are specifically focused on harm prevention in COVID-19 patients.

In addition to review and use of formal guidance and evidence-based recommendations, frontline healthcare personnel have employed creative measures to help ensure patient safety despite the challenges and disruption to usual workflows. For example, the use of baby monitors (which include cameras) with patients in isolation can allow for ongoing contact and communication with the patient without the need to don PPE. As has been discussed in previous Perspectives, the use of telehealth approaches within facilities can also help to limit the number of staff who require direct contact with a patient at any one time. Another example of the initiative of frontline staff is the implementation of rapid-cycle tests of changes to their procedures and documentation protocols to learn what works best for their institution to prevent adverse events under COVID-19 pandemic conditions. As healthcare personnel have sought to innovate in their approaches, their leadership teams have been vital in providing the support and necessary resources.

As more data become available, highlighting where innovative approaches were successful at reducing the risk of adverse events during the pandemic, researchers and policymakers will need to determine if there are particular best practices that may be suitable for continued use beyond the pandemic. This includes not only specific innovation practices, but organizational processes and procedures implemented to facilitate efficient decision making. There may also be further potential for institutions to learn from one another or to create additional standardized protocols and resources for implementation, should additional surge periods occur.


Rhonda Dickman, MSN, RN, CPHQ
Patient Safety Organization (PSO) Director

Tennessee Hospital Association PSO

Brentwood, TN

Poonam Sharma, MD, MPH
Senior Clinical Data Analyst

Atrium Health

Charlotte, NC

Danelle Higgins, MHA, BSN, RN
Patient Safety Organization Administrator

Atrium Health

Charlotte, NC

Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health

IMPAQ International

Columbia, MD

Kate R. Hough, MA
Editor, IMPAQ Health

IMPAQ International

Columbia, MD


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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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