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.[1] 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.[2] 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, provide 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, most 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.”[3]
The report highlights that healthcare systems have faced a significant challenge in seeking to deliver safe care during the pandemic, including:
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:
“… 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.”[6]
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:
Under this broad heading the report groups a wide range of different patient safety issues impacting on the delivery of healthcare services, including:
This theme covers a number of staff safety issues that impact of 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.[8]
This heading groups together a larger number of issues that broadly concern patients, including:
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.
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.
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.
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:
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:
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.[11]
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.
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:
“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.”[12]
Towards the end of this review, the 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:
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.[13]
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.
[1] Patient Safety Learning, Covid-19 – the ongoing impact of the pandemic on patient and staff safety, 14 December 2021. https://www.patientsafetylearning.org/blog/2021-covid-19-the-ongoing-impact-of-the-pandemic-on-patient-and-staff-safety
[2] WHO, Implications of the COVID-19 pandemic for patient safety: A rapid review, 5 August 2022. https://www.who.int/publications/i/item/9789240055094
[3] Ibid.
[4] Rachael Grimaldi, The story behind CARDMEDIC, Patient Safety Learning’s the hub, 28 May 2020. https://www.pslhub.org/learn/coronavirus-covid19/273_blogs/the-story-behind-cardmedic-updated-28-may-2020-r2131
[5] Patient Safety Learning, Why is staff safety a patient safety issue?, 3 September 2020. https://www.patientsafetylearning.org/blog/why-is-staff-safety-a-patient-safety-issue
[6] WHO, Implications of the COVID-19 pandemic for patient safety: A rapid review, 5 August 2022. https://www.who.int/publications/i/item/9789240055094
[7] Healthcare Safety Investigation Branch, COVID-19 transmission in hospitals: management of the risk – a prospective safety investigation, 29 October 2020. https://www.hsib.org.uk/investigations-and-reports/covid-19-transmission-in-hospitals-management-of-the-risk/
[8] Suzanne Shale, Moral injury and the COVID-19 pandemic: reframing what it is, who it affects and how care leaders can manage it, 17 July 2020. https://bmjleader.bmj.com/content/4/4/224.info
[9] NHS Confederation, The unequal impact of COVID-19: investigating the effect on people with certain protected characteristics, 15 June 2022. https://www.nhsconfed.org/publications/unequal-impact-covid-19-protected-characteristics
[10] Patient Safety Learning, Long Covid: Information gaps and the safety implications, 7 June 2021. https://www.patientsafetylearning.org/blog/long-covid-information-gaps-and-the-safety-implications
[11] 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. https://patientsafetyj.com/index.php/patientsaf/article/view/acute-care-analysis-2020/acute-care-analysis-2020-pdf
[12] WHO, Implications of the COVID-19 pandemic for patient safety: A rapid review, 5 August 2022. https://www.who.int/publications/i/item/9789240055094
[13] WHO, Global Patient Safety Action Plan 2021-2030, 3 August 2021. https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan