After years of improvements in patient safety, along came COVID-19

Cracks in the Foundation?

After years of improvements in patient safety, along came COVID-19.

By Mark Thill

Who could doubt the devotion of front-line caregivers, who worked tirelessly during the pandemic under extremely

difficult circumstances? But should the exigencies of COVID-19 necessarily have led to a decline in patient safety? Some industry experts have raised the question.

Patient safety had been on an upward trajectory in the five years preceding the pandemic. During that period, central-line–associated bloodstream infections in U.S. hospitals had decreased by 31%. But that trend was almost totally reversed by a 28% increase in the second quarter of 2020 (as compared with the second quarter of 2019, www.nejm.org/ doi/full/10.1056/NEJMp2118285). Catheter-associated urinary tract infections, ventilator-associated events, and methicillin-resistant Staphylococcus aureus bacteremia increased as well.

Safety also worsened for patients receiving post-acute care, according to data submitted to the Centers for Medicare and Medicaid Services (CMS) Quality Reporting Programs. During the second quarter of 2020, skilled nursing facilities saw rates of falls causing major injury increase by 17.4% and rates of pressure ulcers increase by 41.8%. The surges of the Delta and Omicron variants of SARS-CoV-2 in late 2021 and early 2022 do not bode well for a return to prepandemic levels for any of these indicators.

A lack of resiliency

In mid-February, several experts from CMS and CDC suggested something more than COVID-19 was to blame for the decline in patient safety. In a New England Journal of Medicine perspective piece, “Health Care Safety During the Pandemic and Beyond – Building a System That Ensures Resilience,” they said the pandemic merely exposed the shaky foundation on which patient safety in the U.S. rests.

“We need to re-evaluate whether the health care system has sufficiently invested in ensuring a deeply embedded safety culture and maintaining an unflagging commitment to safety,” they wrote.

“The health care system has been challenged by repeated influxes of vast numbers of very ill patients, which have stretched staff and

Patient safety goals

Following are The Joint Commission’s 2022 Seven National Patient Safety Goals for Hospitals.

1. Identify patients correctly. Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

2. Improve staff communication. Get important test results to the right staff person on time.

3. Use medicines safely. a. Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. b. Take extra care with patients who take medicines to thin their blood. c. Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Give the patient written information about the medicines they need to take. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. 4. Use alarms safely. Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

5. Prevent infection. Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

6. Identify patient safety risks. Reduce the risk for suicide.

7. Prevent mistakes in surgery.

a. Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. b. Mark the correct place on the patient’s body where the surgery is to be done. c. Pause before the surgery to make sure that a mistake is not being made.

Source: The Joint Commission, www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safetygoals/2022/simple_2022-hap-npsg-goals-101921.pdf

supplies. Health care personnel have responded with extraordinary effort and dedication, adapting with unprecedented speed and developing and modifying treatment protocols on the basis of data that have evolved by the week. They have done all these things while battling workforce-safety problems such as exhaustion and a dearth of personal protective equipment, at great risk to themselves and their loved ones. We have seen an increasing number of media reports about the rising incidence of staff burnout, which is causing health care workers to leave practice, retire, or move into other industries.

“The strains on the system have also affected routine safety practices. Overworked clinicians have often had no time for safety rounds, safety audits, or error reporting. Supply-chain disruptions reduced access to personal protective equipment, putting both patients and health care workers at risk. Standard safeguards, such as checklists, quickly became inadequate. Moreover, the pandemic starkly highlighted health disparities, including inequities in the safety of patients and health care personnel.

“It is abundantly clear that the health care ecosystem cannot ask clinicians and staff to work harder, but must instead provide them with more tools and an environment built on a strong foundation of wellness and on instilling and rewarding a culture of safety,” they wrote.

Good enough?

Ana Pujols McKee, M.D., executive vice president and chief medical officer for The Joint Commission, believes the authors of the New England Journal piece were correct. “We should be proud of the strides we have made in patient

“There has been tremendous slippage in safety and performance metrics. It speaks to how our approaches to patient safety are not hard-wired. They collapsed under the pressure of the pandemic.”

safety [over the years]. The question is, should we have been satisfied?”

The statistics showing a decline in safety are “a difficult message to deliver, especially considering that healthcare workers have gone above and beyond to meet the challenges of the pandemic,” she says. “But the data is the data. There has been tremendous slippage in safety and performance metrics. It speaks to how our approaches to patient safety are not hard-wired. They collapsed under the pressure of the pandemic.

“No one has found that magic pill of resilience to patient safety. The sophistication of the skill sets in healthcare in quality and improvement science are way behind that of other highly desirable industries. We know we can move the gauge in patient safety, but the big challenge is sustaining change.

Now what?

“I think there is tremendous room for improvement when it comes to quality and safety, but I don’t believe the governing bodies and leadership have taken on the level of accountability that they should,” says Dr. McKee. That’s the missing link.

“We need a better infrastructure and better partnership between private and public health systems. We also need a more resilient supply chain, and health care organizations to be better prepared for disruption. Additionally, we need to make sure individuals have the right skill sets, resources, and tools to make impactful improvements in safety. If something goes wrong, no one remains silent, and instead, they quickly take action. This dynamic change in culture begins with and is driven by leadership.”

According to the authors of the New England Journal perspective, “The United States deserves breakthrough thinking about systems built on foundational principles of safety, akin to those used in other industries in which safety is embedded in every step of a process, with clear metrics that are aggregated, assessed, and acted on. We also need renewed national goals of harm elimination throughout the health care system and a core safety strategy that includes promoting radical transparency, addressing workforce shortages, and continuing to strive for safety while being sensitive to such tradeoffs as reporting burden and costs. This effort should extend across the continuum of care, beyond the traditional hospital-based safety indicators, and include attention to diagnostic errors and outpatient care.

“The health care sector owes it to both patients and its own workforce to respond now to the pandemicinduced falloff in safety by redesigning our current processes and developing new approaches that will permit the delivery of safe and equitable care across the health care continuum during both normal and extraordinary times. We cannot afford to wait until the pandemic ends.”

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