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Abstract
Introduction Studies on the impacts of COVID-19 on patient safety are emerging. However, few studies have elicited the perspectives of front-line clinicians.
Methods We interviewed clinicians from 16 US hospitals who worked in the emergency department, intensive care unit or inpatient unit during the COVID-19 pandemic. We asked about their experiences with both clinician well-being and patient care throughout the pandemic. We used a rigorous thematic analysis to code the interview transcripts. This study was part of a larger randomised control trial of an intervention to improve healthcare worker well-being during the COVID-19 pandemic; the findings described here draw from clinicians who spontaneously raised issues related to patient safety.
Results 11 physicians and 16 nurses in our sample raised issues related to patient safety. We identified two primary themes: (1) compromised access to healthcare and (2) impaired care delivery. First, clinicians discussed how changes in access to healthcare early in the pandemic–including a shift to telehealth and deferred care–led to delays in accurate diagnosis and patients presenting later in their disease course. Second, clinicians discussed the effects of COVID-19 on care delivery related to staffing, equipment shortages and space constraints and how they deviated from the standard of care to manage these constraints. Clinicians noted how these issues led to patient safety events such as central line infections, patient falls and serious medication administration errors.
Conclusions Several well-intentioned interventions implemented in the early weeks of the pandemic created a unique context that affected patient safety throughout the pandemic. Future pandemic preparedness should consider planning that incorporates a patient safety lens to mitigate further harm from occurring during a public health crisis.
- Patient safety
- COVID-19
- Attitude of Health Personnel
- Standards of care
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Patient safety events affected as many as one in four hospitalised patients in the USA prior to the COVID-19 pandemic. The pandemic created unprecedented circumstances for clinical care that further affected patient safety. Understanding the perspectives of front-line clinicians on patient safety during the COVID-19 pandemic is crucial.
WHAT THIS STUDY ADDS
A national, multidisciplinary sample of clinicians identified multiple, potentially preventable patient safety events and near misses due to compromised access to care and impaired care delivery due to the pandemic.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Future pandemic preparedness should consider planning that incorporates a patient safety lens to prevent further harm during a public health crisis.
Introduction
Prior to the COVID-19 pandemic, one in four hospitalised patients in the USA experienced a patient safety event.1 The emergence of COVID-19 coupled with a lack of preparedness for a global pandemic placed strain on an already fragile public health infrastructure and health systems across the USA.2 This backdrop created a unique context for compromised patient safety.
A patient safety event is defined as a healthcare event that either did or could have resulted in patient harm.3 4 Health systems were overwhelmed by critically ill patients with a novel virus, which was a clear distraction from routine patient safety practices.5 While research on patient safety during the COVID-19 pandemic is emerging, examining patient safety during the pandemic has been difficult.6 Many patient safety events are identified by incident reporting systems that rely on providers. Yet incident reporting, which is often time intensive and underutilised in non-pandemic times,7 decreased even further due to the challenges brought on by the pandemic.5 8 9 Additionally, many of the typical approaches used to identify and address patient safety events (eg, morbidity and mortality conferences and root causes analysis reviews) were suspended during the first wave of the pandemic.5 Even when patient safety events were identified using other methods (eg, billing and electronic medical record data) they were unlikely to capture the breadth of patient safety events that were occurring. A study conducted by the Agency for Healthcare Research and Quality analysed 301 patient safety events submitted to a Patient Safety Organization from March 2020 to October 2020. The most commonly reported events were not actually patient safety events but rather policy and procedure concerns related to COVID-19.10
Nonetheless, through the literature on care processes more broadly, the impact of care disruptions due to COVID-19 on patient safety is starting to emerge.11–14 Many of these studies elicited clinicians’ perspectives to understand patient safety challenges during the pandemic. Clinicians’ impressions are particularly important as a source of information to understand the landscape of patient safety when formal reporting processes decrease.12–16 The majority of these studies, however, focused exclusively on the initial wave of the pandemic12–14 or only on the perspective of critical care physicians.16
To better understand the impact of the multiple waves of the COVID-19 pandemic on patient safety, we conducted a qualitative study of front-line clinicians from multiple disciplines across the USA to understand their perspectives.
Methods
As part of a larger randomised control trial of implementing Stress First Aid, a framework used to improve recovery from stress to front-line healthcare workers (HCWs) during the COVID-19 pandemic,17 57 clinicians from 16 hospitals across the USA (8 intervention and 8 usual care sites) working in the emergency department (ED), intensive care unit (ICU) or an inpatient unit17 were recruited to participate in an interview. Semistructured interviews were conducted by members of the study team (LS, JB, GT, SA and CG) between September 2021 and September 2022.
The interview guide was rooted in the Consolidated Framework for Implementation Research18 and asked respondents about workplace factors that played an important role in their mental health and risk for burn-out. In addition to asking about the perceived effects of the intervention (for intervention sites), clinicians were asked general questions about their experiences as a HCW during the pandemic and how decisions were made about patient care. We conducted an additional set of interviews with 23 registered nurses and physicians from two of the health systems about their experiences as clinicians during the pandemic. For these subsequent interviews, a separate protocol guided respondents throughout different parts of the pandemic, eliciting their general experiences and emotions around providing care at different times in the pandemic. Clinicians from both sets of interviews who spontaneously raised issues around patient safety were included in he analysis for this study.
Interviews were conducted by Microsoft Teams or Zoom and were generally 30–60 min in length. Participants were given a US$50 e-gift card for their participation. The interviews were transcribed, deidentified and uploaded to Dedoose, a qualitative software program for rigorous qualitative coding using a thematic analysis.19 We developed a codebook based on emerging themes identified in initial interviews and updated it as new themes arose. Researchers with experience in qualitative methods (including physician researchers, a health services researcher, a medical sociologist and doctorate-level students in policy analysis) coded (LS, JB, AB, SH and GT) and analysed (LS, JB, SA and CG) the interviews (see Consolidated criteria for reporting qualitative research (COREQ) checklist). Patients and the public were not involved in any stage of the research process given the focus on a HCW intervention.
Results
Of the 80 clinicians interviewed across both sets of interviews, 27 clinicians spontaneously raised issues around patient safety. We identified two primary themes related to patient safety: (1) compromised access to healthcare often resulting in diagnostic delays that may have or did result in patient harm and (2) impaired care delivery that may have or do cause a patient safety events. Table 1 presents additional clinician quotes by theme.
Clinician quotes by theme
Compromised access to healthcare and diagnostic delays
Clinicians discussed how the COVID-19 pandemic affected access to care, particularly preventative care, and how each stage of the pandemic presented new barriers to access. For example, early in the pandemic, when many outpatient clinics transitioned to telehealth and other remote care, clinicians noted that lack of access to in-person care impacted the timeliness of diagnosis and control of clinical conditions (eg, cancers and chronic diseases). Later in the pandemic, patients experienced additional barriers to care due to increased demand for care. Many who deferred care early on or had had care delayed due to early protocols (eg, social distancing and cancelled procedures) to reduce staff and patient exposure to COVID-19, re-entered the healthcare system. Clinicians noted an influx of sick patients with multiple illnesses, many of which were chronic diseases that had acutely worsened during the pandemic’s early months. Clinicians also described serious medical conditions for which delay in diagnosis or treatment may have meant a worse prognosis. One resident physician noted that they had diagnosed more cancers in the ED than ever before, even 2 years after the start of the pandemic, suggesting that without appropriate access to primary care, these cancers were diagnosed at a later stage than they would have been during non-pandemic times.
But you still do see the repercussions of primary care doctors not seeing patients in person for the last two years … I’ve diagnosed more cancer in the ER than I ever thought I would because people had symptoms for a year and then haven’t been able to see a doctor and last resort come to the ER. (Resident Physician)
Impaired care delivery
Staffing concerns
One of the most commonly cited themes was patient safety events related to staffing shortages. Specifically, HCWs discussed the impact of shortages on roles and responsibilities, patient to clinician ratios and the need to hire per diem staff who were less familiar with a given health system. Clinicians reflected on how, early in the pandemic, they felt spread thin as they cared for high volumes of critically ill patients with COVID-19 (eg, more intubated patients than was typical) in addition to caring for other critically ill patients. They deemed this high volume ‘unsafe’. One trainee physician shared how higher than normal patient to clinician ratios led to a patient’s demise. Rather than make more nuanced care decisions and reflect on the patient’s particular clinical situation, the clinician followed a protocol and administered too much intravenous fluid which may have contributed to the patient going into respiratory failure (need for a breathing tube). They felt in non-pandemic times this demise might not have happened. In addition, a nurse shared how the high volume of critically ill patients and patient to nurse ratios meant that one of her patients experienced significant harm that could have resulted in death.
I remember I took care of two Nimbex [a paralytic agent] patients, both paralyzed. Those are supposed to be one to one for safety and I remember I got paired with two Nimbex patients on ventilators and there were tons of drips in each room, IV medications and that was really hard. At [one] point, I remember the propofol [pain and sedative medication] ran out and my patient’s blood pressure was so high, but I was stuck in my other room. … I had to call for help. There was really nobody around because their workload was so heavy that day. So it’s scary. But I just eventually ran over there and hung a new bottle. (Nurse)
Clinicians who were deployed from other units to work in new departments also posed a patient safety risk, as they were less likely to be familiar with clinical conditions and equipment. One nurse noted that delivery of care was ‘compromised’ in part due to staff, who were less experienced with patient-facing or critical care, being deployed from other departments:
It was very stressful during that peak because I felt that we were [delivering] compromis[ed] care because we were just so short staffed …The very little times that they were even able to send staff from upstairs, the other departments, sometimes they would send staff that had not worked at the bedside for years, so their skills weren't up to par, so they weren't as helpful as we would had hoped for. (Nurse)
As the pandemic progressed, staffing shortages seemed to become more acute in multiple departments. Simultaneously, many patients returned to in-person care just as delta and omicron variants were surging. To manage staffing shortages, many health systems started to depend on per diem staff to fill these gaps, which presented its own patient safety issues. These staff were not as familiar with the health system, equipment and other clinical team members, leading to potential or actual patient safety events. One nurse shared how a patient safety event occurred due to a per diem nurse being less familiar with the protocols and equipment in the ICU, noting that while per diem staff had been hired to offload demands on the existing staff, they ultimately created more work.
We had a lot of travel nurses in the past two years and some of them were great, and some of them were horrible. I just remember taking on their load too because they don't know our protocols and they don't know like how to manage our specific ICU patients ….Some of them are not even scanning medications, they're hanging wrong bags like they're hanging Levophed, one that’s a blood pressure [support] medication instead of a fentanyl [a sedation medication]. (Nurse)
This nurse also emphasised the mental load of working with per diem staff—the need to be extra alert to ensure patients remained safe under their care.
Equipment and space
In addition to staffing shortages, clinicians discussed how the pandemic affected resources, including physical space and equipment, and the impact of these deficiencies on care delivery and patient safety. Early in the pandemic, they struggled with inadequate personal protective equipment (PPE) and critical care beds. One nurse, reflecting on the early stage of the pandemic, shared the impact of an inadequate supply of ICU beds,
We had so many ICU patients that they converted the step-down unit… to ICU rooms, which is very unsafe. It’s not like the same monitoring that we use in the ICU… There’s not as much suction, like wall suction, which you need suction for these patients, usually ICU, at least two minimum. There’s just not enough equipment in the room. You can't properly monitor the patients, because their monitors aren't set up for ICU patients…they were forcing us to go out there and take care of patients in conditions that were not safe. (Nurse)
Later in the pandemic, concerns around space and equipment became more widespread. All parts of the health system saw an influx of patients, many of whom had deferred care. Referring to later waves of the pandemic, a resident physician reflected on how overwhelmed their hospital was with both COVID-19 and non-COVID-19 patients, and how they had to practice medicine in ways that were atypical, such as providing critical care in the hallways:
We were coding people in the hallway. We were seeing gunshot wounds in chairs like I was saying. There were so many intensive care unit patients in the emergency department that were crashing all the time …It’s like you are working on minimal resources, minimal room, nursing is always short. So it was just, it just felt unsafe at some times. (Resident Physician)
Deviation from standard of care
Clinicians also described how the challenges they faced affected their ability to provide the standard of care. One clinician shared that, typically, central lines are only reserved for the sickest patients given their risk of causing bloodstream infection. However, due to concerns about maintaining fast and reliable venous access, many more patients received these lines than was typical. Sometimes, due to the sheer volume of ill patients and inadequate staff, these lines remained in place longer than was standard of care resulting in central line-associated bloodstream infections.20 21 Another clinician shared how there were not enough negative pressure rooms (needed to prevent airborne COVID-19 transmission) in their hospital for all their patients with COVID-19, so they attempted to create more negative pressure rooms using an air vent and long tubing. Some patients had falls–a Joint Commission sentinel safety event22–due to the tubing.
Many clinicians shared their feelings of desperation; given the circumstances, they had no other choice but to provide sub-standard care. One nurse stated: ‘It was probably the hardest ethical, mental dilemma that I faced… I can't properly care for my patients because I don't want to bring anybody into the room with me.’ Many clinicians discussed how their health systems changed protocols to reduce staff and clinician exposure to patients with COVID-19 early in the pandemic. These changes occurred when less was known about the virus’s transmission and there were supply chain issues with PPE. In retrospect, they wondered whether this had been the right decision and worried about the impacts of these changes on patient outcomes.
Clinicians also expressed sentiments of moral injury related to these deviations in standard of care and the ethical dilemmas they faced having to choose between quality of care, following new protocols, and their own and their colleagues’ safety. One clinician reflected on the unintended consequences of reduced patient contact during the early months of the pandemic. While clinicians noted that these changes were made for infection control, numerous patients suffered because of the social isolation within the hospital,
We ended up converting a lot of our ER rooms into ICU rooms. So I had one gentleman who was very awake and alert, but his room was like a dungeon…There was no tv and no phone in that room and the internet doesn't work very well down there, so he couldn't even use his own electronic devices. And he literally went crazy. One day I walked in the room he said can you just intubate me, and I said but you don't need it. He goes ‘it will move me out of this place.’ (Attending Physician)
As the pandemic progressed, the usual standard of care continued to be compromised to compensate for the high number of critically ill patients. Although more was known about the virus and there were better tools to both prevent and treat COVID-19, clinicians continued to have to sacrifice patient safety given these new challenges.
Diagnostic anchoring
Clinical care was affected by diagnostic anchoring—the tendency to retain an initial impression even as more information became available.23 Less experienced clinicians had become accustomed to managing ‘only’ COVID-19. Particularly for those early in their training when the pandemic began, COVID-19 may have been one of the few diagnoses with which they had experienced. Even clinicians who were not in training discussed how there were delays in diagnosis of other illnesses because clinicians were focused on ruling out and treating COVID-19.
Everyone was being screened for COVID-19. [but]there’s other things that can cause coughs or shortness of breath besides covid…people get kind of pushed into a bucket of COVID-like symptoms or not. And sometimes those people had heart failure, pneumonia and maybe didn't get the traditional care that they would have. (Attending Physician)
Clinicians also reported not tailoring treatment to the particular clinical condition and treated ‘everyone like they had COVID-19’ even when another diagnoses had been made, which also led to potential patient harm.
Discussion
Our findings add to the literature on clinicians’ perspectives on the effect of the multiple waves of the COVID-19 pandemic on patient safety. Similar to prior studies, the clinicians we interviewed noted that several of the interventions put in place to keep clinicians and patients safe by minimising in-person contact during the early weeks of the pandemic created a unique context that resulted in compromised patient safety.12 As the pandemic progressed, new challenges arose that further affected patient care and exacerbated unsafe conditions, including staffing, equipment and space shortages.13 16 Clinicians also described how the pandemic affected their clinical decision-making—particularly diagnostic anchoring—which may have led to diagnostic errors. They described the emotional toll of the difficult decisions they had to make about patient care during the pandemic. While most clinicians described clinical situations that may have compromised patient care, only a few clinicians shared instances of true patient harm due to these unsafe conditions.
Early in the pandemic, some patients delayed routine care as well as urgent and emergent care out of fear of contracting the virus.24–26 Much routine care was also either cancelled due to surges that threatened health systems’ capacity or managed remotely to avoid in-person contact. Many of the unsafe conditions clinicians shared in this study were the result of processes and protocols that were developed with good intentions to keep both staff and patients safe from a novel, highly transmissible and deadly virus. However, these very efforts delayed needed care, sometimes resulting in late diagnosis of serious medical conditions. Clinicians also reflected on the lasting impact of these decisions even months later as health systems saw high numbers of patients presenting with multiple illnesses, due in part to delays in care. This sentiment is reflected in real-world data; there was a decrease in diagnosis of ‘screening detectable cancers’ (eg, colon cancer) in 2020 compared with 2019. While data are still emerging, reduced cancer screening may mean more cancers diagnosed at an advanced stage.27
Clinicians discussed how the delivery of patient care was reallocated in ways that were unsafe. Critical care was provided in areas that were not conducive to supporting severely ill patients. Staff with limited experience in caring for critically ill patients were also redeployed and asked to provide care beyond the level for which they had been trained. While these decisions were necessary to address surges of patients who would not otherwise have received care, the trade-offs have not been studied. Better understanding and even quantifying the full impact of such decisions could, for example, help health system decision-makers decide when to step down relocation and redeployment efforts because the benefits no longer outweigh the risks.
Isolation precautions to prevent nosocomial spread of COVID-19 may also have had unintended consequences. Drawing on experience from parallel infection control efforts in hospitals–such as contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci–one might expect that putting patients on precautions decreases the frequency of clinician visits into the room. Indeed, prior work on contact precautions suggests an inadvertent increase in patient safety events among those on precautions.28 There is emerging evidence that COVID-19 isolation precautions may have increased the risk of falls and unplanned extubations.6 While we are not suggesting forgoing airborne and contact precautions for COVID-19 patients, we cannot actively guard against the associated harms without better understanding the extent of such harms.
As highlighted in our study, the COVID-19 pandemic forced health systems to make difficult decisions about patient care around COVID-19. However, many of the circumstances described are in part, a result of failures of public health and political systems. Early in the pandemic, the shortage of PPE, testing and ventilators was due to a lack of preparedness months to years before the pandemic started.29 30 It is possible that with optimised public health planning, many of these unsafe conditions and patient safety events could have been prevented. Similarly, the threats to patient safety later in the pandemic (eg, staffing shortages) might also have been averted or at least mitigated. Even prior to the COVID-19 pandemic, the USA had been projected to experience a nursing shortage.31 32 With earlier interventions—such as more funding for nurse education, streamlining credentialing and making it easier for those who trained abroad to enter the workforce31 33—some of the patient safety events described by clinicians in our study possibly could have been prevented.
In the immediate future, healthcare systems continue to be challenged by the pandemic. HCWs are grappling with high levels of burn-out and secondary trauma,34 which only worsens the ongoing staffing and supply shortages. Burn-out has also been associated with medical errors and patient safety events, which suggests a continued threat of patient safety events.35 Given these continued circumstances, health systems, policy-makers and oversight organisations such as the Joint Commission should work together to thoughtfully implement patient-centred policies and practices aimed at reducing harms.
Future pandemic preparedness should also consider planning that incorporates a patient safety lens to identify preventable harms before they occur and to explicitly recognise the trade-offs of pandemic-related decisions. One important deficit highlighted by the current pandemic is the shortcomings of our current systems for identifying patient safety events. Healthcare staff reports of patient safety events, which is the primary source of data on patient safety events, dramatically decreased during the pandemic5 8 9 highlighting the need for more robust systems to identify patient safety events that are less dependent on an already overstretched healthcare workforce. Future research also needs to fully assess the impact of the decisions made during this pandemic such as reduced in-person care, no visitor policies and delayed non-urgent care, to determine if a different approach would have resulted in more or less harm. This will allow the development of crisis standards of care that are mindful of the impact of such decisions on patient safety.
Limitations
Our study had several limitations. First, we did not explicitly ask clinicians about the impact of COVID-19 on patient safety. Rather, these were comments that clinicians spontaneously brought up as part of a larger study on clinician burn-out. Therefore, this study likely under-reports the types and number of patient safety events. However, using these spontaneously raised comments about patient safety also serves to strengthen the findings of this study, as clinicians highlighted patient safety as an important issue in discussing their experiences of providing care during the pandemic. Second, while some clinicians discussed unsafe conditions, we do not know if these events resulted in patient harm; we have no quantitative data on the number of patient safety events at these health systems during the pandemic. Third, we only interviewed nurses and physicians. Other HCWs, for example, respiratory therapists, were also on the front lines and likely have important insights to share about patient safety. Finally, many clinicians shared stories of unsafe care that occurred months prior to the interview so there is the potential for recall bias.
Conclusion
This study provides insight into clinician perspectives on how the COVID-19 pandemic affected patients’ safety. These clinician narratives provide a deeper understanding of the multiple layers of patient safety that were impacted and how each wave of the pandemic presented different challenges to patient safety. Future research is needed to quantify the impact of COVID-19 on patient safety and to identify best practices to reduce risk of such events during future health crises.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by RAND Corporation’s Human Subjects Protection Committee, IRB approval number is 2020-N0697. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors are grateful to our partners at Vizient and Clinical Directors Network for their collaboration, including efforts with recruitment during the pandemic. This work was previously presented at the Society of General Internal Medicine conference on 11 May 2023.
Footnotes
Presented at Poster presetation at Society of General Internal Medicine annual meeting, April 2022, Aurora, CO
Correction notice This article has been corrected since it was first published. Author name 'Shreya Huilgol' has been updated.
Contributors LS accepts full responsibility for the work and conduct of the study, had access to the data, and controlled the decision to publish. LS, JB and CG conceived of the study. LS, JB, AB, SH and GT conducted interviews and coded the results. LS, JB, SA and CG analysed the results. LS took the lead in writing the manuscript. All authors provided critical feedback and helped shape the research, analysis and manuscript.
Funding Research reported in this report was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (PCORI ID: COVID‐2020C2‐10721). Further information available at: https://www.pcori.org/research-results/2020/does-stress-first-aid-program-improve-well-being-among-healthcare-workers-during-covid-19-pandemic-cover-hcw-project.
Disclaimer The statements presented in this article are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.