Delays in Care During the COVID-19 Pandemic in the Veterans Health Administration : The Journal for Healthcare Quality (JHQ)

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Original Article

Delays in Care During the COVID-19 Pandemic in the Veterans Health Administration

Mills, Peter; Louis, Robin Pendley; Yackel, Edward

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Journal for Healthcare Quality 45(4):p 242-253, July/August 2023. | DOI: 10.1097/JHQ.0000000000000383



The purpose of this study was to review patient safety reports in the Veterans Health Administration (VHA) related to delays during an 11-month period that included months of the COVID-19 pandemic.


A retrospective descriptive analysis of COVID-19 patient safety reports related to delays that were submitted in the Joint Patient Safety Event Reporting System database to the VHA National Center of Patient Safety from January 01, 2020 to November 15, 2020 was conducted. There were 897 COVID-19 patient safety events related to delays; 200 cases were randomly selected for analysis, with 148 meeting inclusion criteria.


The results showed delays in laboratory results, level of care, treatment and interventional procedures, specific aspects of care, radiology treatment, and diagnosis. Causes for delays included poor communication between staff, problems in getting laboratory results, confusion over policy, and misunderstanding of COVID-19–specific rules.


Healthcare delays can be reduced during a pandemic by proactively standardizing medical processes/procedures when testing for infection, improving staff to staff communication teaching the SBAR (situation, background, assessment, and recommendations) communication model, and using simulation to identify latent safety issues and educating medical personnel on new protocols related to the pandemic. Simulation can be used to test new protocols developed during the pandemic.

© 2023 National Association for Healthcare Quality

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