COVID-19 Supply Chain Issues Causing ‘Never-Events’ to Happen in Hospitals

“Nurses at the bedside who deliver care to patients need to be consulted when decisions are made that could impact care delivery,” said Karen Goldschmidt, PhD.

The term “wicked problem” may sound like New England slang. In reality, a wicked problem is an incredibly complex issue with multiple factors and interdependencies, that when attempting to solve can reveal other issues that need resolutions.

COVID-19 and pandemic-related supply chain issues caused wicked problems for rural hospitals. Supply chain issues and the lack of supplies during the early months of the pandemic, like personal protective equipment and ventilators, were widely covered in the news. Less is known about other deficient hospital supplies – such as standardized central line insertion and care bundles which help prevent Central Line Blood Stream Infections (CLABSI), a never event which is a preventable health care error.  

Karen Goldschmidt, PhD, an associate clinical professor, and Kelsey Stasko, a graduate student, both in the College Nursing and Health Professions, recently published an article in the Journal of Pediatric Nursing using the occurrence of never events like CLABSI to highlight the wicked problem of global supply chain issues during COVID-19 at a rural children’s hospital and how everyone can better prepare for the next public health emergency.

The article, peppered with personal anecdotes of nurses trading or rationing supplies, explained how even the slightest of delays or disruptions can severely impact patients and their overall care.

Central line bundles, along with the protocols to change central line dressings at specific intervals, significantly reduce patient deaths and rates of disease, as well as health care costs. But because supplies of the central line bundles dwindled, patients went without crucial line changes, as noted in the article. While the ideal number of CLABSIs is zero, the authors explained the rate of CLABSIs increased three-fold at the rural children’s hospital during the 2021-2022 fiscal year.

“When practicing as a NICU nurse in Philadelphia, enormous efforts were made to keep our CLABSI rates at zero. My heart sank when Kelsey shared her experience with me. I realized then how much we take for granted as U.S. nurses and expect that supplies will always be there; there was never a thought in my mind that they wouldn’t be.”

Karen Goldschmidt

Stasko thought it may have spread to other hospitals and that they were expecting a similar shortage. While these supply chain issues may not have been felt at larger, urban hospitals, it is important to recognize the supply chain failures and consider how resources are distributed to care for all patients.

“It felt so remote but also so global,” said Stasko. “We went through known shortages of beds and ventilators during the height of the pandemic. It seems as if the issues surrounding the ‘endemic’ are not as prominent.”

In the article, the authors recollect having to ration supplies which caused delays in changing patients’ IV tubes or central line dressings. Other times, nurses were having to revert back to earlier versions of hospital equipment, which are less technologically advanced and some newer nurses might not have ever seen before. When supplies were replenished with different types from what nurses normally use, there was the added burden of further education on how to use the replacement supplies and extra vigilance to make sure nothing went wrong.

“Patients need supplies to survive,” said Stasko. “Supply and distribution delay or even changes in routinely used brands can severely impact patients and their overall care. Policies are in place for a reason. Evidence-based data has shown that simple measures like tubing changes can improve a patients’ overall health. In other cases, if a unit does not have supplies to support a patient through IV tubes, chest tubes, feeding tubes, etc. we cannot support that patient to live.”

The authors did share what they thought could help in the future, starting with having supply chain failures examined by health care organizations, manufacturers and governments so that improvements or new systems can be put in place to prepare for the next public health emergency.

“In healthcare, we generally interpret the term ‘interprofessional education’ (IPE) to mean learning with other providers from the other health care disciplines (i.e., nurses, physicians, pharmacists, etc.),” said Goldschmidt. “To address complex systems of care such as those that resulted from the global supply chain shortage, we need to expand our definition of IPE to include collaboration with disciplines outside of healthcare. Today, healthcare providers have numerous opportunities to learn with students in emerging fields such as healthcare systems engineering, human factors in design thinking, digital informatics and supply chain management/logistics, all to enhance the quality of care.”

They also recommend that health care organizations consult with the nurses who were on the front lines of the pandemic.

“Nurses at the bedside who deliver care to patients need to be consulted when decisions are made that could impact care delivery,” said Goldschmidt.

Stasko added that she hopes hospitals can see the impact of cost-cutting and other supply disruptions have on patients and staff. And that everyone can realize the impact COVID-19 is still having on supplies.

“It is not limited to toilet paper, gloves and masks. It is affecting supplies that are needed to keep loved ones alive.”

Kelsey Stasko

Media interested in speaking with Goldschmidt or Stasko should contact Annie Korp, news manager, at 215-571-4244 or

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