Covid-19 has posed a huge challenge to the delivery of safe care, both when infection rates were at their highest levels and in terms of its long-term impact on health and social care systems. The pandemic has magnified existing patient safety issues, created new ones, and exposed safety gaps which require systemic responses.
This month the World Health Organization (WHO) has published a new report, Implications of the Covid-19 pandemic for patient safety: A rapid review. The review aims to create a greater understanding of the impact of the pandemic on patient safety, particularly in relation to diagnostic services, treatment and care management. In this blog, Patient Safety Learning, one of the international organisations who contributed to this review, provides an overview and reflections on some the key themes and issues raised in this review.
Providing the background for this review, the WHO introduces this report by highlighting that the pandemic has, and continues to, impact on every facet of healthcare systems across the world. It states that:
“… the unanticipated surge of COVID-19 cases, the pandemic has created an unprecedented demand for care leading to a global strain on health systems, mot of which were not fully prepared to handle large-scale emergencies. The pandemic has emphasized the high risk of avoidable harm to patients, health workers, and the general public, and has identified a range of safety gaps across all core components of health systems at all levels. The impact of the pandemic is still unfolding and will have long-term ramifications.”
The report highlights that healthcare systems have faced a significant challenge in seeking to deliver safe care during the pandemic, including:
- Treating a significantly higher number of patients than normal as a result of Covid surges, while managing the subsequent disruption this has had on non-Covid care and treatment.
- The safety impact of staff shortages because of high numbers of Covid cases.
- Risks to infection control posed by the scarcity of key safety products such as Personal Protective Equipment (PPE).
- The significant toll on healthcare professionals, both in terms of their personal safety and general wellbeing, with heightened work-related stress and burnout.
While it focused on the patient safety challenges that have been posed by the pandemic, it does however highlight some positive developments for patient safety relating to changes to care and treatment during this period:
- The focus on fighting Covid-19 has in some cases functioned as a stimulus to breaking down barriers between individuals and institutions delivering health and social care, encouraging more information sharing and collaborative working.
- We have seen the rapid development of new means to combat the virus, such as vaccines, diagnostics, and therapeutics.
- New positive healthcare innovations and changes to service delivery have emerged in response to pandemic, such as the communication tool CARDMEDIC.
- There has been an increased public awareness of the importance of mental health and caring for healthcare professionals, which is fundamentally linked to ensuring patient safety.
Safety risks and avoidable harm
“… COVID-19 has caused a “perfect storm” in the field of patient safety, and heightened the need to have further research in the area and identify and implement initiatives that ensure safer care, especially in the context of outbreaks and emergencies.”
The core of this WHO report is focused on six interlinked thematic areas where it seeks to summarise the main risks and harm implications of the pandemic for patient safety:
1. Health services
Under this broad heading the report groups a wide range of different patient safety issues impacting on the delivery of healthcare services, including:
- Increased risks of healthcare-associated infections, including Covid-19 transmission in hospitals.
- Safety incidents relating to medication use, including those exacerbated by redeploying staff members to areas they are less familiar with and the absence of family members and carers to provide input and knowledge of patients’ conditions.
- Diagnostic errors involving both patients with Covid-19 and non-Covid conditions, ranging from false negative test results to diagnosis errors because of system strain.
- Disruption to non-Covid care, treatment and diagnostic services.
2. Health and safety of health workers
This theme covers a number of staff safety issues that impact on their ability to deliver safe care, such as exposure and risk of Covid infection, burnout from working in a highly pressured environment, and moral injury as a result of having to make increasingly difficult decisions about prioritising the case for seriously ill patients.
3. Patients, families and communities, including inequities
This heading groups together a larger number of issues that broadly concern patients, including:
- The pandemic both exposing and exacerbating existing health inequalities and gaps in health outcomes.
- Impact of the pandemic on people living in long-term care settings. Patient safety issues here range from high numbers of potentially preventable deaths in care homes to the impact of prolonged periods of isolation with limited visits by friends and family members.
- Restrictions on visitation policies more broadly, concerning both the psychological consequences for patients and the safety consequences when family members and carers are not present to potentially help identify incidents and errors.
- The spread and impact of Long Covid.
4. Leadership, governance and financing
This theme considers the wider impact of the pandemic of healthcare systems, considering the safety roles play by organisational and national leaders, gaps that have been exposed in terms of system preparedness for a pandemic, and the financial impact of this on healthcare systems and their workforces in the long-term.
5. Communication and management of health information
The report notes that the rapid spread of information has been one of the hallmarks of this pandemic, which has itself posed safety challenges. In particularly it cites the risk and harm from misinformation and disinformation about Covid-19, treatments and vaccines, and the limits of health data in countries where the healthcare system itself is under resourced.
6. Development and supply chain of medical products, vaccines and technologies
The final theme is concerned with the safety implications related to products and resources needed to fight the pandemic. It highlights shortages and issues in the global and local supply chain related to essential safety related medical products, such as PPE and vaccines, as examples of this.
Patient Safety Learning’s reflections
We were pleased to be one of the international organisations who were able to contribute to the work of this review. The nature of this type of report however means inevitably there will always be gaps or areas that could potentially have been covered in more depth. Below we highlight three of note:
Long Covid and its safety implications
Millions of people across the world are living with Long Covid, a term created by patients to describe the prolonged, fluctuating symptoms following Covid-19. This WHO review does briefly refer to this under the heading ‘Post-Covid-19 condition’ however we believe this could be significantly expanded upon to include a range of safety issues encountered by people living with this condition, including:
- Inconsistent care and contradicting advice.
- Public health messaging not reflecting of the risks associated with Long Covid.
- How people living with Long Covid should be communicated and engaged with.
- Knowledge gaps among healthcare professionals on the nature of Long Covid and good practice in diagnosis and treatment.
Patient safety reporting during the pandemic
Another area this report also touches on, where we believe further research is needed, concerns the disruption of routine patient safety activities during the pandemic, in particular patient safety incident reporting.
In our view, this area requires a much more detailed review as healthcare systems still have a limited understanding of the impact on avoidable harm. We cannot clearly say whether there has been an increase in avoidable harm in this period. At the height of Covid infections, many healthcare systems de-prioritised reporting of incidents of unsafe care, redirecting staff time to clinical care and other pandemic related activities. On paper this has resulted in a reduction in reports of unsafe care, most likely to be because of reductions in reporting.
Most of our existing estimates of levels of avoidable harm in health and social care still pre-date the pandemic. With less reporting and fewer investigations taking place during this period, we are less knowledgeable about the scale and causes of avoidable harm. Without this knowledge and insight, health systems are going to be compromised in their understanding and less able to respond to with appropriate and targeted action.
Ongoing disruption and recovery of non-Covid care and treatment
Understandably much of the focus of this review is on the impact of the Covid-19 pandemic on patient safety at the height of infection levels. In this context it does consider in some detail the safety implications of the disruption to non-Covid care, treatment and diagnostic services.
We believe that in considering the implications of the Covid-19 pandemic on patient safety, there is a compelling case for further work being required looking at the long-term impact of the disruption it has caused to healthcare systems and its ongoing impact. This includes, but is not limited to:
- Safety challenges in prioritising and reducing backlogs in care and treatment.
- Long-term needs of patients who have significantly deteriorated while waiting for care and treatment.
- Managing these challenges in the face of global healthcare workforce shortages.
Turning insights into action
“Significant opportunities lie ahead for patient safety improvement in the context of the pandemic. Many instances of risks and avoidable harm identified in this rapid review are still ongoing and if unaddressed are likely to prevail again no matter what pathogen the next pandemic will involve.”
Towards the end of this review, WHO identify a number of potential opportunities and activities to build on lessons learned from the pandemic. Below we highlight several actions they identify which we believe all countries should be actively reviewing and considering how they can be applied to their healthcare systems:
- The report highlights numerous safety risks, varying from adequate infection and prevention control measures to overburdened workforces. There needs to be additional research and action in each of these areas on a country-by-country basis.
- More work is needed to identify best practices and lessons learned from this period, which can help to inform future interventions and contribute to building safer and more resilient health systems.
- Healthcare systems should seek to build on successful advances in areas such as digital innovation, increasing transparency, open and frequent bidirectional communication, data sharing, collaboration, and teamwork with the breakdown of traditional silos, and the rapid adoption of selected patient safety practices.
- There should be a concerted effort to develop protections for the health, safety and well-being of healthcare professionals. These should be aligned with patient safety, infection prevention and control, and other health workforce programmes.
- There is an opportunity to embed patient safety in design and development of health care systems, products and processes.
- Further work should be undertaken to employ multidisciplinary approaches to patient safety, which could yield lessons to inform the development and implementation of patient safety strategies and innovations for a safer healthcare systems.
- Health systems need to be better prepared for unexpected and emerging threats and seek to address current structural inequities.
While the above points are taken from this report, they are not constituted as formal recommendations. The main thrust toward the end of this review is to point towards the recently developed WHO Global Patient Safety Action Plan 2021-2030 as providing a comprehensive framework to address the safety gaps identified in this report.
We believe there would be value in the WHO inviting all countries and healthcare systems to reflect on the findings of this review and formally consider the implications of Covid-19 on their health system. They could then report back on their assessment and the improve actions they aim to deliver, in the context of the Global Patient Safety Action Plan, enabling the WHO to collate and assess this to take forward learning and action in a collective global drive to reduce avoidable harm.
9. Shawn Kepner and Rebecca Jones, 2020 Pennsylvania patient safety reporting: an analysis of serious events and incidents from the nation’s largest event reporting database. Patient Saf. 2021; 3(2): 6-21.