When we look at the impact of the COVID-19 pandemic through the perspective of patient safety and health quality reports we can see that patient safety is often compromised by the virus. Several causes of patient safety error can often be identified in reports and healthcare resource pressures, availability of staff and so on caused by COVID-19 and the knock-on effect is often a major contributing factor.
However, systemic, long-standing patient safety cultural failings can also be identified, and it is important to separate the two. We should not lay all patient safety failings at the door of COVID-19 and miss out on doing ‘deep dives’ into why adverse incidents have occurred and learning the lessons from them.
We should not become too accepting of risk and to taking short cuts because of the pandemic. We can see from daily news stories the toll that COVID-19 is exacting on hospitals and the heroic response of nurses, doctors, and others, under extreme pressure. Hospital trusts declare critical incidents over staff shortages and, despite the very best efforts of staff, many patients will not receive the level of care and experience that would normally be given:
‘Aaron Cummins, whose trust serves patients in Lancashire and south Cumbria, wrote in an internal message to staff: “Sadly, despite everyone's best efforts, many of our patients are still receiving a level of care and experience that falls below the level of standards we would like.’
In battlefield working conditions patient safety errors will be made even by staff trying their very best to ensure that they don't occur. In many senses of the word, COVID-19 has put a profound strain on the concept of patient safety carrying out best practice.
Inspection reports: looking for systemic failings
We can see the strains on the system through inspection reports and the accompanying summary news releases from the Care Quality Commission (CQC). Some of these strains can also be seen to have existed in pre-pandemic times. Some patient safety errors identified are systemic—ingrained within the hospital culture—including poor record-keeping or not reporting errors, though they might also have been exacerbated by the pandemic. Some errors can simply be put down to shoddy professional practice and are unforgivable by any measure, such as Never Events.
Two reports on CQC inspections illustrate these points. The first relates to The Princess Alexandra Hospital NHS Trust in Harlow, Essex (CQC, 2021a). There were positives in the report, but these were eclipsed by the negative findings. Some key issues identified can also be viewed as possibly systemic, hospital culture failings and may not be totally related to COVID-19 pressures.
Philippa Styles, CQC's head of hospital inspection, stated:
‘We recognise the enormous pressure that NHS services are under and that usual expectations can't always be maintained but it is important that hospital trusts do all they can to mitigate risk within the resources available to them. It was very concerning that inspectors had to intervene to ensure two patients in the waiting area with deteriorating conditions and at risk of harm were given medical attention. Once admitted into hospital, timely observations weren't always carried out or recorded meaning patients could be placed at risk.’
The CQC listed several improvements that must take place. These included, for urgent and emergency services:
- Sufficient numbers of suitably qualified, skilled and experienced nursing staff to meet the needs of patients
- A trust-level review of clinical risk assessments, care planning and physiological observations to ensure patients' needs are individualised, recorded and acted upon
- Ensuring every patient has an initial assessment to identify and triage the most urgent cases.
Meanwhile, in other medical areas there were requirements for risk assessment regarding falls and pressure ulcers, and appropriate preventive measures. In addition, the report highlighted that:
‘ Patient records must be completed in a timely manner
Staff must follow systems and processes to safely prescribe, administer, record and store medicines.’
The second inspection, at North Devon District Hospital (CQC, 2021b), found that:
‘ There was a shortage of medical and nursing staff which meant patient safety was not always maintained
Staff identified patients at risk of deterioration, but they did not always provide care in a timely manner. The system of allocation of patients to doctors in some areas was not clear and led to confusion for nursing and medical staff when patients needed urgent medical review
Sometimes staff did not report near misses, as they were not aware it was their responsibility to do so. This meant that the opportunity to learn from incidents and near misses was often lost
Care records were not always complete and/or legible. Medicines were not always well managed.’
Reporting incidents should never be viewed as a waste of time
There were positive findings in the report, and it is important to balance all these together. However, as so often is the case with CQC inspection reports, the bad findings outweigh the good. A concerning finding was made in relation to staff management and error reporting. This could be regarded as being attributed to the prevailing patient safety culture in the trust, although resource pressures brought about by COVID-19 may well have exacerbated the situation. It can be difficult, in practical terms, to separate out failings brought about by COVID-19 from more systemic, organisational culture failings.
‘It was also very concerning to hear a few staff were labelled negatively by their managers for reporting too many incidents. This was preventing other staff from coming forward to report incidents, especially in relation to being short staffed. Staff told us they were sometimes too busy to report incidents and felt little was done about them anyway.’
Imagine if in the aviation industry adverse safety incidents were not reported because staff felt that nothing much would happen when they were reported. Also, that some managers were negatively labelling some staff for reporting too many incidents. Would passengers and staff be willing to fly on an airline that maintained that attitude? Clearly, there would be a crisis of confidence and that airline would soon go out of business.
The same thinking should be applied to our hospitals but sadly this is not always the case. Patients will still attend a hospital despite dire warnings of patient safety failings. They are, in a sense, a captive audience and many have no choice but to attend their local NHS hospital.
From these two inspection reports we can see that some findings and issues cannot be explained away or excused by the COVID-19 pandemic. It does appear that several adverse findings are related to the existing culture of the hospitals, although it can be difficult to separate the two. Many of the failings identified in these reports are generally well known in the NHS and can be seen in several reports going back many years.
Never Events
Never Events continue to occur in our hospitals, and some have even morphed into ‘common Never Events’ as they don't seem to abate. This raises fundamental issues of patient safety and the tolerance for these types of events in the NHS. Yes, we accept that health care demands that fallible human beings perform complicated tasks on other human beings and that sometimes errors will be made, that the best we can do is try to minimise the possibility of risk occurring, and that we do this in an often resource-compromised environment. That said, Never Events cannot be excused and are dire failings by any measure.
Recent figures on Never Events from NHS England/NHS Improvement (2022) are concerning. The report states that 278 Serious Incidents appeared to meet the definition of a Never Event in the list accompanying the 2018 framework (https://tinyurl.com/mr2vczbj) and had an incident date between 1 April and 30 November 2021; this number is subject to change as local investigations are completed. Reported Never Events as set out in Table 2 of the document included:
- Wrong site surgery: 117, counting 9 cases of procedures intended for another patient
- Retained foreign object post procedure: 66, including guidewires, parts of drill bits not identified as missing at the time, and swabs
- Wrong implant/prosthesis: 35.
The fact that many of these Never Events continue to be reported is a cause for concern. It is upsetting to think that in 9 months there could be, for example, 6 cases of ‘injection to the wrong eye’, 36 cases of a block administered to the wrong site, or two cases of a stoma to the stomach instead of the colon.
Conclusion
We can all learn from the reported patient safety errors of the past and the CQC inspection reports are helpful in informing us of organisation and individual failings. These reports can usefully form educational and training case studies in courses and workshops on patient safety.
In viewing patient safety within the context of a COVID-19 pandemic it is important to try to separate out the adverse healthcare incidents that are occurring purely because of the pandemic from those occurring because of the poor patient safety culture in a trust. In practice, however, it can be very difficult to make a distinction.
We should be careful not to let staff and management become too risk tolerant because of the pandemic. We must still report and thoroughly investigate adverse healthcare incidents.
If a patient is negligently injured by nurses and doctors, then they can claim compensation in the courts. The court will take account of all the circumstances of the case into account. COVID-19 pressures would be considered in setting the legal standard of care to be exercised in a particular case. However, it should not be viewed as ‘get out of jail free card’ in every case. There will be complicated legal issues to resolve. For further reading on this issue I recommend that readers seek out the discussion by Tomkins et al (2020).