Adverse Patient Safety Events During the COVID-19 Epidemic

Area of Science:

• Healthcare quality and safety
• Infectious disease epidemiology

Background:

• The COVID-19 pandemic introduced unprecedented challenges to healthcare systems globally.
• Patient safety events require continuous monitoring and analysis to ensure quality care delivery.

Purpose of the Study:

• To analyze patient safety events related to COVID-19 within the Veterans Health Administration (VHA) system.
• To identify common event types, locations, and causes during the initial year of the pandemic.

Main Methods:

• A retrospective descriptive analysis of patient safety events was conducted.
• Data were sourced from the Joint Patient Safety Event Reporting System and Root Cause Analysis databases (March 2020 - February 2021).
• Events were systematically coded for type, location, and cause.

Main Results:

• The most frequent patient safety events were delays in care and staff/patient exposures to COVID-19.
• Other reported events included elopements, laboratory errors, and wrong procedures.
• Common causes involved procedural confusion, care disruption due to COVID-19, and failure to promptly identify infected patients.

Conclusions:

• Findings align with other studies on pandemic-related patient safety.
• Recommendations emphasize strengthening safety culture, developing staff support tools, enhancing communication, and leveraging expertise in system redesign.