June 2020 DOI:10.33940/data/2020.6.3
Patient Safety Concerns in COVID-19–Related Events A Study of 343 Event Reports From 71 Hospitals in Pennsylvania
​Author Biographies


Matthew A. Taylor, PhD, Patient Safety Authority
Matthew A. Taylor (MattTaylor@pa.gov) is a patient safety analyst at the Patient Safety Authority.

Shawn Kepner, MS, Patient Safety Authority
Shawn Kepner is a data analyst and statistician at the Patient Safety Authority.

Lea Anne Gardner, PhD, RN, Patient Safety Authority
Lea Anne Gardner is a patient safety analyst at the Patient Safety Authority.

Rebecca Jones, MBA, RN, Patient Safety Authority
Rebecca Jones is the director of Data Science and Research for the Patient Safety Authority.


COVID-19 (i.e., coronavirus disease 2019) was declared a pandemic and has had a profound impact on healthcare systems, which may increase the risk of patient harm. We conducted a query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to identify COVID-19–related events submitted by acute care hospitals between January 1 and April 15, 2020. We identified 343 relevant event reports from 71 hospitals and conducted a descriptive study to identify the prevalence of and relationships between 13 categories of associated factors and six categories of event outcomes. We found that 36% (124 of 343) of events had more than one associated factor and 24% (83 of 343) had more than one outcome. The most frequently identified factors were Laboratory Testing (47%; 161 of 343), Process/Protocol (25%; 87 of 343), and Isolation Integrity (22%; 74 of 343). The two most frequent outcomes were Exposure to COVID-19 Positive or Suspected Positive Patient (50%; 173 of 343) and Missed/Delayed Test or Result (31%; 108 of 343). Finally, the findings showed that seven of the associated factors had a notable impact on the frequency of Exposure to COVID-19 Positive or Suspected Positive Patient outcome. Overall, we anticipate that the results can be used to identify areas of greatest need and risk, which could help to guide allocation of resources to mitigate risk of patient harm.

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