Challenges and Potential Solutions for Patient Safety in an Infectious-Agent-Isolation Environment: A Study of 484 COVID-19-Related Event Reports Across 94 Hospitals


  • Matthew A. Taylor, PhD Patient Safety Authority
  • Catherine M. Reynolds, DL, MJ, RN Patient Safety Authority
  • Rebecca Jones, MBA, RN Patient Safety Authority



airborne precautions, droplet precautions, contact precautions, ergonomics, human factors, isolation design, isolation room, SARS-CoV-2, coronavirus, pandemic, patient safety, patient harm, risk mitigation


Isolation- visual abstract

Previous research has shown that patients in infectious-agent isolation are at greater risk for certain types of safety-related events. We conducted a study to explore the relationship between the various types of events that occur in an isolation environment and the associated factors, which may have implications for the likelihood of the event and severity of patient harm. We conducted a query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to identify event reports submitted by acute care hospitals between January 1 and September 30, 2020. We identified 484 relevant event reports from 94 hospitals for inclusion in our descriptive study (excluding near-miss events). We measured the frequency of relationship between categories of safety-related event types and 18 categories of associated factors. Among the seven categories of event types, the most frequently identified were skin integrity (141 of 484, 29%), falls (129 of 484, 27%), and medication-related (78 of 484, 16%). Across all 18 categories of associated factors, which had or may have had an influence on the event type, the most frequent were patient’s mental status (80 of 484, 17%), staff’s time to don personal protective equipment (62 of 484, 13%), and patient’s interference with equipment/supplies (45 of 484, 9%). Overall, our results revealed that the frequency of certain associated factors varied considerably from one event type to another, which indicates that the relation between event types and associated factors should guide selection of risk mitigation strategies. We encourage readers to leverage our results along with Table 9, which provides a list of challenges identified in an isolation environment and potential solutions. We envision hospital staff proactively and systematically using the information in our manuscript to facilitate their evaluation of the isolation environment and prioritization of risk mitigation strategies.

Author Biographies

Matthew A. Taylor, PhD, Patient Safety Authority

Matthew A. Taylor ( is a patient safety analyst for the Patient Safety Authority (PSA), where he conducts research; uses data to identify patient safety concerns and trends; and develops solutions to prevent recurrence, as well as tools and materials to help facilities and clinicians improve patient safety. Prior to joining the PSA, Taylor was a scientific writer and research specialist at the University of Pittsburgh School of Pharmacy, and he has served fellowships at the Centers for Disease Control and Prevention (CDC) and the VA Pittsburgh Healthcare System. His expertise in data analysis and research covers a range of topics, including patient safety, public health, employee training, process efficiency, human factors, workplace culture/climate, behavior change interventions, and organizational management.

Catherine M. Reynolds, DL, MJ, RN, Patient Safety Authority

Catherine M. Reynolds is a patient safety liaison with the Patient Safety Authority, working directly with more than 80 healthcare facilities in the Southeast region of Pennsylvania to improve patient safety through consulting, education, and collaboration. She is an accomplished healthcare and patient safety professional, specializing in the analysis of adverse events and facilitywide implementation of patient safety plans. With more than 20 years of experience in healthcare, she has served as a registered nurse and quality improvement coordinator in Philadelphia-area hospitals, including as patient safety manager for the Einstein Healthcare Network. She has been published in Patient Education and Counseling and The Joint Commission Journal on Quality and Patient Safety.

Rebecca Jones, MBA, RN, Patient Safety Authority

Rebecca Jones is director of Data Science and Research at the Patient Safety Authority, where she also founded and serves as director of the Center of Excellence for Improving Diagnosis. Her previous roles at the PSA include director of Innovation and Strategic Partnerships, and regional patient safety liaison. Before joining the PSA, Jones served in various roles leading patient safety efforts and proactively managing risk in healthcare organizations. She currently is chair of the Practice Committee of the Society to Improve Diagnosis in Medicine and serves on the Advisory Committee of the Coalition to Improve Diagnosis.


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patient in bed, with a doctor writing on a chart, wearing an isolation suit. There's a wall behind the patient, with coronavirus particles trying to get in.



How to Cite

Taylor, M. A., Reynolds, C. M., & Jones, R. (2021). Challenges and Potential Solutions for Patient Safety in an Infectious-Agent-Isolation Environment: A Study of 484 COVID-19-Related Event Reports Across 94 Hospitals. Patient Safety, 3(2), 45–62.



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