December 2020
​Author Biographies


Lea Anne Gardner, PhD, RN, Patient Safety Authority
Lea Anne Gardner ( is a patient safety analyst with the Patient Safety Authority. She has more than 30 years of research experience in patient safety, performance improvement, cardiology, and behavioral health, and a diversified work experience, including roles as a national director of quality improvement and population health and institutional review board administrative director, a coronary intensive care nurse, a clinical research nurse, and a nurse research/leadership preceptor.




Acute respiratory distress syndrome (ARDS) and respiratory failure are characterized by hypoxemia (i.e., low levels of blood oxygen). Infections such as influenza and COVID-19 can lead to ARDS or respiratory failure. Treatment is through supportive measures. In severe cases, patients receive oxygen through a ventilator and, when appropriate, are placed in a prone position for an extended period. A retrospective review of events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) identified 98 prone position–related events in patients with ARDS, respiratory failure, distress, and pneumonia from January 1, 2010, through June 30, 2020; 30 events were associated with COVID-19. Skin integrity injuries accounted for 83.7% (82 of 98) of the events. The remaining events, 16.3% (16 of 98), involved unplanned extubations, cardiac arrests, displaced lines, enteral feedings, medication errors, a dental issue, and posterior ischemic optic neuropathy.


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