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

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January 12, 2022

This piece discusses patient safety challenges that arose as a result of the unique care circumstances surrounding the COVID-19 pandemic, particularly at the height of the pandemic in 2020.

Quality and safety in hospital pediatrics during COVID-19: a national qualitative study.

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De Angulo NR, Penwill N, Pathak PR, et al. Hosp Pediatr. 2021;Epub Dec 24.

This study explored administrator, physician, nurse, and caregiver perceptions of safety in pediatric inpatient care during the first months of the COVID-19 pandemic. Participants reported changes in workflows, discharge and transfer process, patient and family engagement, and hospital operations.

Don't go to the hospital alone: ensuring safe, highly reliable patient visitation.

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Gandhi TK. Jt Comm J Qual Patient Saf. 2022;48:61-64.

Families and caregivers play an important role in ensuring patient safety. At the start of the COVID-19 pandemic and, to a lesser extent, during surges, family and caregiver visitation was severely restricted. This commentary advocates reassessing risks and benefits of restricted visitation, both during the pandemic and beyond.

Use and impact of virtual primary care on quality and safety: The public's perspectives during the COVID-19 pandemic.

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Neves AL, van Dael J, O’Brien N, et al. J Telemed Telecare. 2021;Epub Dec 12.

This survey of individuals living in the United Kingdom, Sweden, Italy, and Germany identified an increased use of virtual primary care services – such as telephone or video consultation, remote triage, and secure messaging systems – since the onset of the COVID-19 pandemic. Respondents reported that virtual technologies positively impacted multiple dimensions of care quality, including timeliness, safety, patient-centeredness, and equity.

In conversation with Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO

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January 12, 2022

Patient Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers to promote learning.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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January 11, 2022

Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.

NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency, 2021.

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Rockville, MD: Agency for Healthcare Research and Quality; November 2021. AHRQ Pub. No. 22-0005.

This analysis of reports submitted by Patient Safety Organizations during the early months of the COVID pandemic found that patients testing positive for COVID-19 or being investigated for carrying the virus was the most frequently reported patient safety concern (26.6%). In addition, patients and staff being exposed to individuals who had tested positive for COVID-19 was identified as a patient safety issue in 18.2% of the records analyzed.

Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.

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Shen L, Levie A, Singh H, et al. Jt Comm J Qual Patient Saf. 2022;48:71-80.

The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.

Age-related COVID-19 vaccine mix-ups.

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National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021.

Vaccine missteps are known to occur during flu and COVID-19 inoculation efforts. This announcement raises awareness of misadministration of COVID vaccines associated with patient age. It highlights storage protocols as one approach to minimize mistakes. This alert is part of a national program to distribute learnings from report analysis to improve medication safety.

Nursing strategies to safeguard COVID-19 patients from harm in the intensive care unit.

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Shiner D, Bock B, Simpson C, et al. Crit Care Nurs Q. 2021;45:13-21.

This article discusses how the COVID-19 pandemic has impacted nursing care, highlighting implications on hospital-acquired infections, patient safety events (such as falls and medication errors), and patient mental health.

Race, ethnicity, and 60-day outcomes after hospitalization with COVID-19.

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Robinson-Lane SG, Sutton NR, Chubb H, et al. J Am Med Dir Assoc. 2021;22:2245-2250.

The COVID-19 pandemic has exacerbated racial and ethnic disparities in healthcare. This study used registry data to examine racial and ethnic disparities in post-discharge outcomes among patients hospitalized with COVID-19. Findings indicate that Black patients may be more vulnerable to COVID-19-related complications (e.g., higher 60-day readmission rates) and extended recovery periods (e.g., longest delays in returning to work).

Patients went into the hospital for care. After testing positive there for Covid, some never came out.

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Jewett C. Kaiser Health News. November 4, 2021.

Nosocomial infection is a primary concern due to the COVID pandemic. This news story examines instances when inpatients contracted, and sometimes died of, COVID-19 while receiving care for a different condition. It summarizes the challenges associated with collecting adequate data that completely document nosocomial spread of COVID-19 and its impact on patient outcomes.

Supervision, interprofessional collaboration, and patient safety in intensive care units during the COVID-19 pandemic.

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Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2:397-414.

The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.

Critical care simulation education program during the COVID-19 pandemic.

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Leibner ES, Baron EL, Shah RS, et al. J Patient Saf. 2022;18:e810-e815.

During the first surge of the COVID-19 pandemic, a rapid redeployment of noncritical care healthcare staff was necessary to meet the unprecedented number of patients needing critical care. A New York health system developed a multidisciplinary simulation training program to prepare the redeployed staff for new roles in the intensive care unit (ICU). The training included courses on management of a patient with acute decompensation with COVID-19, critical care basics for the non-ICU provider, and manual proning of a mechanically ventilated patient.

Transmission of community- and hospital-acquired SARS-CoV-2 in hospital settings in the UK: a cohort study.

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Mo Y, Eyre DW, Lumley SF, et al. PLoS Med. 2021;18:e1003816.

Nosocomial transmission of COVID-19 is an ongoing concern given the pressures faced by hospitals and healthcare workers during the pandemic. This observational study using data from four hospitals in the United Kingdom found that patients with hospital-onset COVID-19 (compared to suspected community-acquired infections) are associated with high risk of nosocomial transmissions to other patients and healthcare workers.

Patient, surgeon, and health care worker safety during the COVID-19 pandemic.

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Hölscher AH. Ann Surg. 2021;274:681-687.

In 2020, the World Health Organization prioritized healthcare worker safety as a way to maintain patient safety. This article describes several initiatives aimed at protecting surgeons, patients and healthcare workers implemented since the beginning of the COVID-19 pandemic.

Ensuring primary care diagnostic quality in the era of telemedicine.

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Willis JS, Tyler C, Schiff GD, et al. Am J Med. 2021;134:1101-1103.

Telemedicine has become a more accepted care mode due to the COVID pandemic and general rural care access issues. This commentary suggests a 5-part framework for examining patient, physician, technological, clinical and health system influences on care management decisions that affect the safety of telediagnosis in primary care.

Battle Buddies: rapid deployment of a psychological resilience intervention for health care workers during the COVID-19 pandemic

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October 27, 2021

The relationship between burnout among healthcare workers and poor patient safety outcomes has been well-documented

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

The less-discussed consequence of healthcare's labor shortage.

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Bean M, Masson G. Becker's Hospital Review. October 4, 2021.

Staffing shortages can impact the safety of care by enabling burnout, care omission, and staff attrition. This article discusses how the COVID-19 pandemic has necessitated an examination of how staffing challenges affect areas such as diagnosis, infection control, and organizational patient safety focus.

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