Patient Safety Concerns in COVID-19–Related Events
A Study of 343 Event Reports From 71 Hospitals in Pennsylvania
COVID-19 (i.e., coronavirus disease 2019) was declared a pandemic and has had a profound impact on healthcare systems, which may increase the risk of patient harm. We conducted a query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to identify COVID-19–related events submitted by acute care hospitals between January 1 and April 15, 2020. We identified 343 relevant event reports from 71 hospitals and conducted a descriptive study to identify the prevalence of and relationships between 13 categories of associated factors and six categories of event outcomes. We found that 36% (124 of 343) of events had more than one associated factor and 24% (83 of 343) had more than one outcome. The most frequently identified factors were Laboratory Testing (47%; 161 of 343), Process/Protocol (25%; 87 of 343), and Isolation Integrity (22%; 74 of 343). The two most frequent outcomes were Exposure to COVID-19 Positive or Suspected Positive Patient (50%; 173 of 343) and Missed/Delayed Test or Result (31%; 108 of 343). Finally, the findings showed that seven of the associated factors had a notable impact on the frequency of Exposure to COVID-19 Positive or Suspected Positive Patient outcome. Overall, we anticipate that the results can be used to identify areas of greatest need and risk, which could help to guide allocation of resources to mitigate risk of patient harm.
Sauer LM. What is Coronavirus? Johns Hopkins Medicine website [updated May 11, 2020. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus.
WHO Timeline - COVID-19: World Health Organization website; 2020 [updated May 11, 2020]. Available from: https://www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19.
Coronavirus Disease 2019 (COVID-19): Situation Summary: Centers for Disease Control and Prevention website; 2020 [updated May 11, 2020]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/summary.html.
Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020;382(10):929-36. Epub 2020/02/01. doi: 10.1056/NEJMoa2001191. PubMed PMID: 32004427; PubMed Central PMCID: PMCPMC7092802.
Adhanom T. WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19 - 11 March 2020: World Health Organization website; [updated May 11, 2020]. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.
Holloway R, Rasmussen SA, Zaza S, Cox NJ, Jernigan DB, Workgroup IPF. Updated Preparedness and Response Framework for Influenza Pandemics. MMWR Recomm Rep. 2014;63(6):1-18.
Wolf Administration Confirms Two Presumptive Positive Cases of COVID-19: Pennsylvania Governor Tom Wolf website; 2020 [updated March 6, 2020May 14, 2020]. Available from: https://www.governor.pa.gov/newsroom/wolf-administration-confirms-two-presumptive-positive-cases-of-covid-19/.
Department of Health Provides Update on COVID-19, 1,145 Positives Bring Statewide Total to 26,490: Pennsylvania Media website; 2020 [updated May 14, 2020]. Available from: https://www.media.pa.gov/Pages/Health-Details.aspx?newsid=773.
Bartsch SM, Ferguson MC, McKinnell JA, O’Shea KJ, Wedlock PT, Siegmund SS, et al. The Potential Health Care Costs And Resource Use Associated With COVID-19 in the United States: A Simulation Estimate of the Direct Medical Costs and Health Care Resource Use Associated With COVID-19 Infections in the United States. Health Aff. 2020:10.1377/hlthaff.2020.00426.
Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002).
Centers for Disease Control and Prevention. Standard Precautions 2018 [cited 2020 May 13]. Available from: https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/standard-precautions.html.
Centers for Disease Control and Prevention. Healthcare Infection Prevention and Control FAQs for COVID-19 2020 [cited 2020 May 13]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html.
Centers for Disease Control and Prevention. Using Personal Protective Equipment (PPE) 2020 [cited May 13, 2020]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html.
Pham JC GT, Pronovost PJ. What to Do With Healthcare Incident Reporting Systems. J Pub Health Res. 2013;2:154-9.
Pronovost PJ TD, Holzmuller CG, Lubomski LH, Dorman T, Dickman F, Fahey M, Steinwachs DM, Engineer L, Sexton JB, Wu AW, Morlock LL. Toward Learning From Patient Safety Reporting Systems. J Crit Care. 2006;21:301-15. doi: 10.1016/j.jcrc.2006.07.001. PubMed Central PMCID: PMC17175416.
World Health Organization. Influenza: Pandemic Preparedness 2020 [cited May 13, 2020]. Available from: https://www.who.int/influenza/preparedness/pandemic/en/.
Centers for Disease Control and Prevention. Pandemic Preparedness Resources 2020 [cited 2020 May 13]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/php/pandemic-preparedness-resources.html.