The PSNet Collection

COVID-19 Focused Inspection Initiative in Healthcare.

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Occupational Safety and Health Administration. March 2, 2022.

The impact of nursing home inspections to ensure the quality and safety of the service environment is lacking. Weaknesses in the process became more explicit as poor long-term care infection control was determined to be a contributor to the early spread of COVID amongst nursing home residents. This announcement outlines a targeted inspection initiative to assess whether organizations previously sited have made progress toward improving workforce safety.

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.

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.

Using ventilator splitters during the COVID-19 pandemic--letter to health care providers.

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Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration; February 9. 2021.

Lack of access to ventilators during the COVID-19 crisis has necessitated care compromises to support multiple patients. This situation can reduce the effectiveness of monitoring patients on shared devices and introduce other challenges. This communication provides insights to enhance the safety of multiple-patient ventilator use.

Wear face masks with no metal during MRI exams.

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FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020.

Magnetic resonance imaging (MRI) requires patient preparation steps to protect against inadvertent harm. This announcement cautions patients and providers to assess masks being worn to protect against COVID-19 transmission for metal components that can result in patient burns during the exam. Recommendations for safety include enhanced screening to ensure masks are safe for the exam environment.

National Nursing Home COVID Action Network.

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Rockville, MD: Agency for Healthcare Research and Quality; September 2020.

Nursing home residents are especially vulnerable to COVID-19 due to their age, and communal living conditions, and nursing home staff are among the most at-risk essential workers. In partnership with the University of New Mexico’s ECHO Institute and the Institute for Healthcare Improvement (IHI), AHRQ has established this network to prevent infections among nursing home residents and staff. All nursing homes that are certified to participate in the Medicare and Medicaid programs will be able to participate in a 16-week training program that includes peer-to-peer, case-based learning and additional mentorship from local and national experts. The training program will include best practices for using personal protective equipment, COVID-19 testing, clinical management of asymptomatic and mild cases, and other topics.

Health Worker Safety: A Priority for Patient Safety.

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Geneva, Switzerland: World Health Organization; September 17, 2020.

The intersection of worker well-being and safety with patient harm prevention has become apparent due to COVID-19. This report discusses five areas of importance in motivating lasting change in health care environments to support the safety of the work force. It highlights policy and strategy alignment, occupational considerations, violence reduction, psychological concerns, and physiological harms as essential elements of a robust approach to workforce safety improvement.

Covid-19: Assessing the Risk to Public Protection Posed by a Doctor as a Result of Concerns about their Practice during the Pandemic.

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London, UK: General Medical Council; September 14, 2020.

Physician caregiving effectiveness can be tested during crisis situations. This guidance shares recommendations for leaders assessing complaints against physicians during the COVID-19 pandemic to consider extenuating circumstances when determining next steps in managing the response to poor care delivery.

Paediatric International Patient Safety and Quality Community.

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Paediatric International Patient Safety and Quality Community. 525 University Ave, Suite 630, Toronto, Ontario M5G 2L3, Canada.

The safety of children receiving health care is a recognized challenge. This community provides educational and collaborative opportunities for specialists seeking to improve the safety of pediatric patient populations. It recently expanded its content to include a new section on COVID-19 and Patient Safety.

Northeastern University Hospital Surge Capacity Planning Model: Bed, Ventilator, and PPE 1-30 Day Demand.

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Rockville, MD; Agency for Healthcare Research and Quality: 2020.

The COVID-19 pandemic is placing surge demand and strain on health organizational, department, and unit-level capacity and personnel. This announcement features a prototype tool as a model for health systems to evaluate hospital-specific demand for medical and intensive care unit beds and the needed equipment to equip staff to keep patients safe during shifting conditions associated with providing care during an emerging crisis.

Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups.

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The COVID-19 pandemic has revealed weaknesses in health care systems worldwide that have affected drug distribution, worker safety and health equity. This report provides a stakeholder analysis of societal conditions affecting patients with coronavirus in the United Kingdom. The authors conclude that racism and discrimination must be considered to correct inequities that impact safe care for Black Asian Minority Ethnic (BAME) patients to effectively respond to COVID-19.

Ensuring Healthcare Safety Throughout the COVID-19 Pandemic.

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US Health and Human Services Office of the Assistant Secretary for Preparedness and Response’s Technical Resources, Assistance Center, & Information Exchange; US Health and Human Services/FEMA COVID-19 Healthcare Resilience Task Force. June 2, 2020.

Health systems are rapidly adjusting processes to successfully respond to COVID-19 crisis demands. This webinar featured tactics used and discussed initiative results to inform continued improvement. The speaker roster included Jeff Brady, MD and Rollin (Terry) Fairbanks, MD.

Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.

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Washington, DC: United States Government Accountability Office; May 20, 2020. Publication GAO-20-576R.

This US Government Accountability Office (GAO) report highlights the chronic shortfalls in nursing home infection control programs. The GAO analyzed survey data from the Centers for Medicare & Medicaid Services (CMS) and found 82% (13,299) of nursing homes surveyed were cited in one or more years between 2013-2017 and in each individual year, 40% of nursing homes had infection control and prevention deficiencies that continued through 2018 and 2019. While the majority of the citations did not indicate harm to nursing home residents and were rarely associated with enforcement actions, the GAO intends to examine CMS oversight of infection and control in the near future. In light of the COVID-19 pandemic, these findings are particularly concerning.

Circle Up for COVID-19 Training.

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Circle Up for COVID-19 Training. Center for Medical Simulation.

Communication strategies are important for engaging staff in behaviors that support effective teamwork. This website highlights a process that involves briefings, supportive conversations, and debriefings as a communication structure for use during COVID-19 care episodes and other complex interactions.

Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.

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Washington DC: Office of the Inspector General; April 3, 2020. Report no. OEI-06-20-00300.

Frontline perspectives provide organizations with knowledge to inform improvement. This report summarizes survey results exploring organizational strategies to address workforce and patient safety challenges stemming from the current COVID-19 pandemic response.

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