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Patient Safety Complaints Received During the COVID-19 Pandemic

05/07/2021

By John Michael Delacruz, Patient Safety Specialist and Madhavi Dave, Patient Safety Specialist

“I have been using the same mask all day to treat COVID patients,”

“My organization is telling us to use trash bags as PPE.”

“Our patients are eating too close together and I’m afraid of bringing the virus home to my family”

These were just some of the patient safety event reports The Joint Commission’s Office of Quality and Patient Safety received in the terrifying early days of the COVID-19 pandemic. It’s nothing new to us to hear complaints about accredited health care organizations. That’s happened every day in our 25-year history and we’re honored with the public’s trust to help organizations improve. In a typical year, our department receives about 22,000 reports of possible patient safety events.

In 2020, individuals reported approximately 16,000 potential patient safety events and a whopping 3,539 reports were all related in some way to COVID-19.
As the dust began to settle in the latter part of 2020, we performed an in-depth analysis of the patient safety event reports we received. While we hope to never experience another global pandemic, there’s certainly value in being prepared. It’s the first time we’ve ever aggregated our data in this way and we hope our accredited organizations use this information to develop their own specific lessons learned from the pandemic.

Safety & Sentinel Events
These patient safety reports originated from a variety of sources, such as:

  • staff
  • patients
  • family
  • anonymous individuals
  • media

The vast majority of complaints were considered “Safety Events”, most of which are not a threat to a patient’s immediate health and safety. The safety events mainly fell within several leading areas of focus, including:

  • assessment and care/services 
  • infection control
  • organizational structure

The more serious allegations are referred to as Sentinel Events. These have the most far-reaching consequences to patients, including death and severe harm. Of the 48 sentinel events reported, leading areas of focus included:

  • care management (i.e. delays in care, falls)
  • surgical/invasive issues (i.e. complications)
  • protection events (i.e. suicide)

One interesting finding is that all of these 48 sentinel events’ outcomes were influenced by COVID-19.  Half of the patients involved had tested positive for the virus. 

Breakdown by Care Areas
To make this research as meaningful as possible to our accredited organizations, we separated the data by care setting and found some interesting differences.

As expected, the vast majority of patient safety complaints were linked to accredited hospitals. Infection control and assessment of care/services were the leading focus areas. Specific concerns included:

  • lack of COVID-19 testing
  • inadequate COVID-19 screening
  • services interrupted or not available
  • rapidly changing COVID-19 criteria

Infection Control Concerns
The other settings had a sharp drop off in complaints, but all noted infection control concerns. Settings studied included:

  • behavioral health
  • ambulatory health
  • nursing care centers
  • home care
  • critical access hospitals

Organizations in all of these settings had issues with infection control.  Specific apprehensions included:

  • inadequate disinfection/ cleaning
  • lack of mask/PPE availability
  • inconsistent hand hygiene
  • COVID outbreaks within organization
  • lack of adherence to CDC guidelines

Complaints Against Health Care Organizations
A smaller—but significant—number of complaints were directed at the health care organizations and their handling of the pandemic. These targeted organizational structure and rights and ethical concerns,  including:

  • lack of training or precautions
  • expose/ill staff expected to work
  • emergency management plans not activated
  • inconsistent visitor policies
  • denied requests for relocation
  • medical decisions made without power of attorney
  • lack of compassionate care

We know that every patient and every staff member has a different COVID reality and this is reflected in the patient safety reports. We’ve never publicly shared the trends around patient safety reports but it seemed important to do so now. Anecdotally speaking, the complaints we’re receiving now seem less COVID-19 focused than they did a year ago. Still, it’s our hope that many of our accredited organizations can use this information to further improve patient safety.

Madhavi Dave is a Patient Safety Specialist in the Office of Quality and Patient Safety. Prior to this position, she worked in several decision support roles at leading Chicagoland hospitals.


John Delacruz is a Patient Safety Specialist in Joint Commission’s Office of Quality and Patient Safety. Prior to this role, he served as administrative director for pathology and laboratory medicine as well as radiology and diagnostic imaging at Norwegian American Hospital.