ArticlePDF AvailableLiterature Review

Take-Home Messages from the COVID-19 Pandemic: Strengths and Pitfalls of the Italian National Health Service from a Medico-Legal Point of View



The World Health Organization (WHO) declared the outbreak of the Coronavirus disease-2019 (COVID-19) infection a pandemic on 11 March 2020. As of the end of October 2020, there were 50 million cases of infection and over one million deaths recorded worldwide, over 45,000 of which occurred in Italy. In Italy, the demand for intensive care over the course of this pandemic crisis has been exceptionally high, resulting in a severe imbalance between the demand for and availability of the necessary resources. This paper focuses on elements of preventive medicine and medical treatments in emergency and non-emergency situations which, based on the international scientific literature, may prove to be useful to physicians on a behavioral level and avert professional liability problems. In order to achieve this objective, we have performed a search on MEDLINE to find published articles related to the risks associated with the pandemic that contain useful suggestions and strategies for mitigating risks and protecting the safety of the population. The results have been collocated in line with these specific study areas.
Take-Home Messages from the COVID-19 Pandemic: Strengths
and Pitfalls of the Italian National Health Service from a
Medico-Legal Point of View
Matteo Bolcato 1, * , Marco Trabucco Aurilio 2, Anna Aprile 1, Giulio Di Mizio 3, Bruno Della Pietra 4and
Alessandro Feola 4
Citation: Bolcato, M.; Aurilio, M.T.;
Aprile, A.; Di Mizio, G.; Della Pietra,
B.; Feola, A. Take-Home Messages
from the COVID-19 Pandemic:
Strengths and Pitfalls of the Italian
National Health Service from a
Medico-Legal Point of View.
Healthcare 2021,9, 17. https://
Received: 24 November 2020
Accepted: 22 December 2020
Published: 25 December 2020
Publisher’s Note: MDPI stays neu-
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1Legal Medicine, Department of Molecular Medicine, University of Padua, 35121 Padova, Italy;
2Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy;
3Forensic Medicine, Department of Law, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy;
4Department Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (B.D.P.); (A.F.)
*Correspondence:; Tel.: +39-081-778-316
The World Health Organization (WHO) declared the outbreak of the Coronavirus disease-
2019 (COVID-19) infection a pandemic on 11 March 2020. As of the end of October 2020, there were
50 million cases of infection and over one million deaths recorded worldwide, over 45,000 of which
occurred in Italy. In Italy, the demand for intensive care over the course of this pandemic crisis has
been exceptionally high, resulting in a severe imbalance between the demand for and availability
of the necessary resources. This paper focuses on elements of preventive medicine and medical
treatments in emergency and non-emergency situations which, based on the international scientific
literature, may prove to be useful to physicians on a behavioral level and avert professional liability
problems. In order to achieve this objective, we have performed a search on MEDLINE to find
published articles related to the risks associated with the pandemic that contain useful suggestions
and strategies for mitigating risks and protecting the safety of the population. The results have been
collocated in line with these specific study areas.
COVID-19; medical liability; ethics; medico-legal evaluation; patient blood management;
clinical risk management
1. Introduction
The World Health Organization (WHO) declared the outbreak of the Coronavirus
disease-2019 (COVID-19) infection a pandemic on 11 March 2020. The infection can cause
severe respiratory insufficiency, sometimes requiring hospitalization in an intensive care
unit (ICU) in order to provide invasive ventilatory support [
]. The outcome may be
fatal, despite the use of considerable professional and economic resources, equipment,
and facilities, especially in older patients and with the development of acute respiratory
distress syndrome (ARDS). In one particular cohort of 1591 patients admitted to ICU in
Lombardy between 20 February and 18 March 2020, the mortality rate was 26% [
]. The
pandemic has attacked and, in many cases, deeply unsettled various aspects of our view
of and relationship with life, society, and rights, raising critical issues and limitations that
were previously believed to have been totally overcome. Nevertheless, Italy recognizes
and guarantees every individual the protection of fundamental rights, including the right
to health (Article 32 of the Constitution), the right to safety (Article 16), and the right
to personal freedom (Article 13). In addition, the Italian legal system contains various
Healthcare 2021,9, 17.
Healthcare 2021,9, 17 2 of 13
provisions detailing how to avail oneself of these rights, including the right to refuse
medical assistance, even if the purpose is to prolong life [37].
Despite efforts on hospital and national levels to raise the quality and efficacy of
healthcare, the demand for intensive care over the course of this pandemic crisis has been
exceptionally high, resulting in a severe imbalance between the demand for and availability
of the necessary resources. This situation has raised unprecedented dilemmas and situa-
tions [
], which the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive
Care (SIAARTI) addressed in a document entitled: “Clinical ethics recommendations for
the allocation and suspension of intensive care treatments in exceptional, resource-limited
circumstances” [
]. This document provides a concrete analysis of the issue which involves
a complex and detailed procedure. It also proposes a method for the ethical-scientific
evaluation of ICU admission criteria, described by the various healthcare professionals and
operators involved [10].
Furthermore, to stem the spread and severity of the pandemic, national and European
authorities issued numerous emergency provisions of a logistical and economic nature to
suspend production activities and movement, including a general lockdown on economic
and social activities that lasted until the beginning of May 2020 [
]. Thereafter began a new
phase of coexistence with the virus in circulation with protection measures in place mostly
consisting of personal hygiene, protection of airways using masks, and social distancing.
As of the end of October 2020, there were 50 million cases of infection and over one
million deaths recorded worldwide, over 45,000 of which occurred in Italy [12,13].
The epidemiological situation in Italy seems to be relatively under control, despite the
slight and continual increase in cases of infection.
New and significant challenges have emerged due to the need to coexist with the
virus until a sufficient population immunity threshold has been reached, primarily through
vaccination. This paper focuses on elements of preventive medicine and medical treatments
in emergency and non-emergency situations which, based on the international scientific
literature, may prove to be useful to physicians on a behavioral level and avert professional
liability problems. Furthermore, as part of this literature review, we have analyzed articles
that contain recommendations of strategies and conduct to mitigate pandemic-related risks
and to protect the population.
2. Materials and Methods
Search Strategy
We searched for all articles written in English in the literature available on MEDLINE
in the last year until 31 October 2020 using the following search terms: “medical liability
SARS-CoV-2,” “medical liability COVID-19,” “medical liability pandemic,” “malpractice
SARS-CoV-2,” “malpractice COVID-19,” “medico-legal litigation SARS-CoV-2,” “medico-
legal litigation COVID-19,” “liability claims SARS-CoV-2,” and “liability claims COVID-19.”
The objective of this review is to concentrate on articles and documents that contain useful
information on prevention techniques for containing dissemination and contamination
within the broader program of clinical risk management. We included only articles available
in the literature that contain information concerning pandemic-related situations of risk and
that recommend the implementation of specific activities designed to mitigate these risks
and facilitate the proper operation of strategic sectors to protect the population. Articles
that contained merely clinical or microbiological indications regarding the nature and
characteristics of the virus were excluded. All sources were evaluated independently by
two of the authors to determine their relevance to the present study and then selected for
inclusion by all the authors.
3. Results
Using the above search strings, MEDLINE produced 53 results that the authors
considered relevant to the study in that they contain useful information for the prevention
of adverse events despite the persistence of the pandemic. Details of the documents
Healthcare 2021,9, 17 3 of 13
analyzed and excluded are displayed in PRISM format in Figure 1. In order to facilitate
comprehension of the text, we have collocated the results according to the specific study
areas and reviewed them in a paragraphical narrative.
Healthcare 2021, 9, x 3 of 13
3. Results
Using the above search strings, MEDLINE produced 53 results that the authors
considered relevant to the study in that they contain useful information for the preven-
tion of adverse events despite the persistence of the pandemic. Details of the documents
analyzed and excluded are displayed in PRISM format in Figure 1. In order to facilitate
comprehension of the text, we have collocated the results according to the specific study
areas and reviewed them in a paragraphical narrative.
Figure 1. Flowchart depicting the choice of studies.
3.1. Healthcare and Safety of Care
In the course of a pandemic, reaching a high level of care safety [14,15] may prove to
be a complex challenge [16]. It is clear that healthcare professionals have concerns re-
garding professional liability disputes that arise due to pandemic-related issues [17–19].
During this particular pandemic, several countries have contemplated creating a legal
shield that limits the professional liability of healthcare personnel throughout this
emergency situation [20,21]. More specifically, in March 2020, pending the approval of
the Cura Italia Decree, certain amendments were issued stipulating that a healthcare
worker shall be held liable only if the alleged harm caused to the patient is caused di-
rectly by malicious misconduct or gross negligence, where gross negligence represents an
unjustified violation of the basic principles that govern the healthcare profession or of
any emergency protocols established to handle the situation [22–26]. Furthermore, it was
feared that various profiles of liability may ensue in connection with the following sce-
(a) Lack of or reduced ability to care for and treat infected patients due to the insuffi-
ciency of available resources, which has contributed to causing harm or patient
(b) Harm to or death of patients not infected by COVID-19 but affected by ingravescent
diseases (e.g., tumors or cardiopathy) indirectly caused by the pandemic, the reduc-
Figure 1. Flowchart depicting the choice of studies.
3.1. Healthcare and Safety of Care
In the course of a pandemic, reaching a high level of care safety [
] may prove to be
a complex challenge [
]. It is clear that healthcare professionals have concerns regarding
professional liability disputes that arise due to pandemic-related issues [
]. During
this particular pandemic, several countries have contemplated creating a legal shield
that limits the professional liability of healthcare personnel throughout this emergency
situation [
]. More specifically, in March 2020, pending the approval of the Cura Italia
Decree, certain amendments were issued stipulating that a healthcare worker shall be
held liable only if the alleged harm caused to the patient is caused directly by malicious
misconduct or gross negligence, where gross negligence represents an unjustified violation
of the basic principles that govern the healthcare profession or of any emergency protocols
established to handle the situation [
]. Furthermore, it was feared that various profiles
of liability may ensue in connection with the following scenarios:
(a) Lack of or reduced ability to care for and treat infected patients due to the insufficiency
of available resources, which has contributed to causing harm or patient death.
Harm to or death of patients not infected by COVID-19 but affected by ingravescent
diseases (e.g., tumors or cardiopathy) indirectly caused by the pandemic, the reduction
Healthcare 2021,9, 17 4 of 13
of available healthcare resources, or the cessation of medical activities pertaining to
non-pandemic-related infirmities preventing access to adequate, timely care.
(c) Patient infection within hospitals or residential facilities used as shelters due to failure
to observe prevention recommendations and protocols.
(d) Infection and consequent harm to or death of employees in ill-prepared companies, or
more likely, hospitals and residential care homes that lack adequate safety equipment.
Harm to or death of patients infected with COVID-19 and treated with experimental
or off-label drugs.
Before analyzing each of the hypothetical profiles listed above, it is worth remember-
ing that from a general point of view the Italian legal system, even without specific liability
exemption laws, contains certain important institutions that relate to this situation. Regard-
less of the specific liability profile envisaged, the fact that there is no scientific evidence
available regarding the nature, transmissibility, and treatment for the SARS-CoV-2 infection
necessitates careful consideration. At the time this document was drafted and even less
so towards the beginning of the epidemic, there were no guidelines or recommendation
documents based on solid evidence that could provide reasoned and specific direction to
guide medical decisions. In effect, with no covering laws, this meant extreme difficulty in
delineating either proper or censurable conduct with scientific certainty.
The second aspect of interest concerns the effect a substantial lack of hospital resources
has on the decisions made by individual operators, liability for which in no way attributable
to the operator personally but to institutional decision-makers. This is a particularly
significant factor in criminal proceedings where liability is necessarily attributed to a
specific person.
The profile of liability described in point (a), where an individual operator is unable
to administer life-saving treatment due to insufficient resources [
], represents the
legal scenario of inability to perform a service for reasons not attributable to the healthcare
professional. The professional would therefore be exempted from any compensation
obligation pursuant to Articles 1218 and 1256 of the civil code. These laws are more easily
applied within the context of personal liability as opposed to the liability of facilities,
which are obliged to demonstrate their inability to fulfill their duties due to (objectively)
unpredictable and unavoidable causes [
], to a crisis and to an inability to ensure the
standard of care previously delivered [
]. To that end, Article 2236 of the civil code may
be invoked, which sanctions that “If performing the service requires the solution to particularly
difficult technical problems, the service provider is not liable for damages in the absence of malicious
misconduct or gross negligence.” According to some authors, this provision could serve as
an initial shield against possible attacks, especially if brought for speculative purposes.
Furthermore, the provision set forth in Article 9 of Law No. 24/2017 on recourse states: “In
order to quantify damages, with the exception of the provisions set forth in Law No. 20, 14 January
1994, Art. 1 (1b) and Art. 52 (2) of the consolidated act referred to in Royal Decree No. 1214, 12
July 1934, particularly difficult situations, including those of an organizational nature, that affect
public health or social care facilities in which healthcare professionals operate must be taken into
account (
. . .
).” Although said provision refers to recourse claims, it is clear that it also
implies that certain organizational difficulties may enable the quantum of compensation to
be regulated. The epidemic that has developed in Italy can without doubt be classified as a
medical, scientific, and organizational situation of exceptional difficulty.
In light of these provisions, although an ad hoc law to limit professional medical
liability may not seem necessary, high-level legal assessment and medico-legal abilities [
compliant with the methodological and scientific precision required [37,38], are essential.
3.2. Future of the Healthcare System
However, there is still the issue of liability for the decisions of those who have caused
the national situation of general unpreparedness and the constant reduction of social and
public healthcare services by failing to implement policies that foresee both developing and
unanticipated exigencies and situations. Such shortsightedness, the reasons and associated
Healthcare 2021,9, 17 5 of 13
liability for which shall be analyzed, has not only led to a failure to safeguard human
dignity, given in many cases it is impossible to allocate adequate treatment resources to
some patients, but also, no less dramatically, to healthcare professionals being obliged to
implement decisions they would never have wanted to implement.
Though this situation has defined the initial stages of the pandemic, it cannot be
allowed to become the norm in future crisis stages. For that reason, regional and national
initiatives must be activated to increase available therapeutic resources in preparation for a
further rise in demand. Such an increase may require action on three levels: (1) intensive
care, (2) internal medicine, and (3) community care.
As regards the first level, national institutions have made significant contributions in
the past few months. Prior to the pandemic (2017), there were 5090 intensive care spaces
available in Italy (8.42 per 100,000 inhabitants) [
], whereas the Ministry of Health is
currently aiming to reach 8500 spaces by October. This increase may serve to prevent
situations where a number of patients have no access to intensive care and the potential
medical, social, and legal repercussions. These statistics are calculated on a national basis,
but, as was noted in the first wave in March and April 2020, the pandemic did not affect all
areas of the country with equal intensity [
]. Although the Italian National Health Service
is organized on a regional basis, active and effective cooperation between all regions is
essential in order to put available resources to the most effective use on a national level.
Treatment during the pandemic has required not only intensive care unit admission
but also considerable assistance from entire medical and surgical departments, which have
been transformed into reception areas for infected patients. This influx of patients has had
two basic effects: (1) interruption of surgical care and treatment of other diseases that do
not require urgent intervention, and (2) filling departments with infected patients
This has affected certain geographical areas more than others and involved assisting and
treating many patients. However, in the event the pandemic were to place a further
substantial burden on the health service, employing the same measures as were adopted a
few months ago is not an option in that it is not feasible, due to public health and ethical-
legal liability concerns as regards sick patients, especially the chronically ill, to impose
another substantial suspension on ordinary activities [4547].
With respect to point (b), in order to prevent this legal scenario, home medical care
services for patients infected with COVID-19 who do not need hospital or intensive care
will have to be enhanced. This approach has been incentivized through the extensive hiring
of healthcare personnel for community care, especially nurses, who can provide support
to sick people and their families in isolation at their homes or in designated facilities to
prevent the spread of infection and enable full physical recovery. It will also prevent
hospital congestion and facilitate the normal practice of non-pandemic-related medical
and surgical services [
]. This level of organization requires action on two fronts: (1)
application of strict protocols to ensure patient safety, and (2) implementation of systemic
strategies for handling acute shortages.
As regards point (1), accurate assessments of patient conditions are essential so as to
decide whether to hospitalize or whether home care would be sufficient. This assessment
should be carried out by trained medical personnel and subjected to periodic reviews by
means of remote monitoring systems so that if the situation were to deteriorate, the patient
could be hospitalized in time and, if necessary, admitted to intensive care [
]. Therefore,
shared operating protocols are needed both to assist practitioners and to integrate models
of conduct to prevent professional and organizational liability implications.
3.3. Patient Blood Management
In relation to point (2), plans and strategies to manage severe crisis situations must
be formulated on an institutional level, even when resources are available, making full
use of all the options that scientific innovation presents. As a result, in times of greater
difficulty, all available technical solutions can be utilized to ensure the continuity of es-
sential medical-surgical activities and to develop not only logistical and economic but
Healthcare 2021,9, 17 6 of 13
also scientific responses to crises. An example of the type of proactivity needed to ensure
such continuity during emergency situations would be the proper management of blood
resources. Maintaining adequate supplies of safe blood in order to guarantee the execution
of necessary surgical procedures or other medical activities can prove to be particularly
difficult in emergency situations, especially epidemics. In the first few months of the
pandemic, many countries [
], including Italy [
], experienced a consistent decrease
in donations and, therefore, in the availability of hematic products. Although to date
there is no evidence to suggest the possibility of virus transmission through blood from
symptomatic individuals, the shortage is due to the greater difficulty in travel, the risks
associated with congregating in donation centers, and a higher percentage of the popu-
lation that is potentially infected and unable to donate. This decrease has not produced
devastating consequences on the population and on medical activities, since the decision
to postpone non-urgent surgeries was taken simultaneously and, therefore, the demand for
hematic products decreased considerably [
]. Nevertheless, this new-found balance
cannot be maintained; routine activities cannot be interrupted again at the expense of
public health. A systematic, proactive, and organized approach is needed to meet this type
of demand such as patient blood management (PBM).
PBM is a multidisciplinary, multimodal approach adopted to limit or eliminate the
need for allogenic blood transfusions through evidence-based management of anemia,
blood loss reduction, and optimization of blood salvage strategies [
]. This approach
comprises over 100 methods and activities with the aim of optimizing the use of the
patient’s blood instead of resorting to allogenic blood transfusions [
]. In addition to
reducing transfusion risks [
], PBM is also proving instrumental in applying the law on
patient safety in Italy [
]. It does, however, necessitate consistent and systemic planning
and management if it is to be a dependable resource in times of severe crisis [6265].
The implementation of PBM presents both a challenge and a particularly profitable
opportunity in Italy and other countries with an older average population. In the years
ahead, these countries will find themselves unable to satisfy the transfusion demand, as the
population will not be in a position to donate blood due to old age despite their potential
need to receive it. In that sense, the pandemic may accelerate the instituting of processes to
safeguard public health in addition to presenting a remarkable opportunity for economic
saving [66].
3.4. Residential Care Homes
With regard to point (c), in recent months there has been significant media attention,
particularly because of the high number of deaths in residential care homes for the elderly
due to, according to critics, superficial management of admissions and preventative activi-
ties to create a safe environment for the frail that occupy it [
]. It is important to state that
the prevention of respiratory infections in such contexts is particularly complex and poses
a challenge [
] on several fronts: firstly, the frailty of elderly patients in conjunction
with the scarcity of clinical manifestations which can present late and are thus difficult to
detect in a timely manner. Secondly, nursing homes often lack the specialized personnel
and equipment needed to deal with acute events [
]. In emergency situations, many
residential facilities in Italy have had to treat and assist infected patients who were not
promptly hospitalized. This can easily create exposure to medico-legal litigation. Therefore,
it is imperative that risk management programs be set up in every facility in order to deal
with this pandemic effectively [71].
While the level of unpreparedness during the initial stages of the pandemic may have
been justifiable, the current situation necessitates that there be no further procrastination in
the implementation of strategies to improve care by means of early diagnosis of signs and
symptoms, the use of standard diagnostic criteria, the adoption of adequate preventive
measures, and the institution of monitoring and control systems. Such measures will
simultaneously increase the probability of optimizing results and ensure the safety of
patients and the well-being of workers [
]. Further indications include the institution
Healthcare 2021,9, 17 7 of 13
of internal coordination committees, periodic employee and patient screening programs,
careful selection of personal protective equipment (PPE), promotion of training initiatives
that all members of staff must attend as well as the necessary logistical activities for
organizing isolation and monitoring procedures.
From a medico-legal standpoint, each facility needs to prepare internal protocol
documents with clear behavioral indications for all operators, including a precise plan of
action to guarantee safe crisis management. The objective of such documents, registered
and shared with all facility personnel, is to ensure that all those concerned act responsibly
and to provide an effective, documented defense in the event of litigation [7477].
3.5. Safety of Employees
Scenario (d) highlights the need to ensure the safety of employees, especially health-
care employees, as they are deemed at greater risk of infection. On 24 March 2020, an agree-
ment between the Italian government and representatives for companies and employees
was proposed and subsequently adopted on 24 April 2020 [
]. The main recommendations
of the agreement have been summarized in Table 1.
Table 1.
Main recommendations listed in the agreement between the Italian government and representatives for companies
and employees signed on the 24 March 2020.
Using the most appropriate and effective methods, the company shall
inform all employees, and any who enter the premises, of the provisions
to contain the spread of the virus and of the rules to be followed. This
information should include: the obligation to stay at home in the event of
a fever above 37.5
C, maintain safe distances, observe handwashing and
hygiene rules, and to inform one’s employer of any flu-like symptoms
that appear during the work period in a timely and responsible manner.
Methods for accessing the workplace and checks
that shall be performed Measurement of body temperature, triage.
Hygiene in the workplace
The company shall ensure the daily cleaning and periodic sanitization of
workstations, common rooms/areas, and entertainment facilities. The
company shall provide appropriate handwashing detergents and
recommend frequent handwashing with soap and water. In the event a
certain work-related activity necessitates proximity between workers of
less than one meter and no other organizational solutions are available,
the use of masks and other protective equipment is mandatory.
Handling a symptomatic person in the workplace
In the event someone present in the workplace develops a fever and
symptoms of respiratory infection such as a cough, said person must
report to the personnel office immediately and be isolated. The company
shall immediately inform the competent healthcare authorities and call
the COVID-19 emergency numbers.
Role of the occupational health physician
The doctor shall assist the company in prevention activities and
screening, if required, of employees as well as reporting potentially
fragile employees.
The Italian government supports the implementation of these recommendations
as they promote the safety and protection of workers, forming the basis for the safety
activities that companies must adopt, including for the purposes of preventing litigation.
Healthcare personnel must be included among the category of workers who, being in
constant contact with infected patients, are at greater risk of infection. This factor was
particularly highlighted during the initial weeks of the epidemic due to the severe shortage
of PPE. This brings to mind the high number [
] of physicians who died of COVID-
19 infection and the National Institute for Insurance against Accidents at Work (INAIL)
declaration in favor of compensating those affected [80].
Finally, as far as liability in the event of harm or death caused by the use of experi-
mental or off-label drugs is concerned, Italian law permits and delimits their usage (Law
Healthcare 2021,9, 17 8 of 13
No. 94/98). Despite the fact that the use of off-label drugs may expose a patient to potential
risks, in the specific context of the pandemic—considering the scarce knowledge of the
virus’ mechanism of action and target organs—physicians must show greater prudence in
resorting to such drugs. Evaluations of proper conduct shall take into account the specifics
of the case, the severity of the patient’s clinical manifestations, the nature of the drug,
known contraindications, verified side effects, and the dosage administered.
3.6. Administration of Justice and Scientific Research
Since the beginning of the year, Italy has experienced a lockdown that is even more
dangerous from a social viewpoint—that of the justice system. Particularly, the justice
system has been paralyzed and come to a standstill with the exception of cases of extreme
urgency and gravity. This has caused a series of problems with regard to maintaining the
country’s social and economic system. The motive for the lockdown is the fear of potential
infection in courtrooms and of court employees. However, as things stand, the justice
system must be reactivated as soon as possible in order to prevent further delays in the
country’s economic activities. To do so safely, courts can take advantage of all the available
technological and organizational resources at their disposal, e.g., videoconferencing sys-
tems, certified electronic signatures, and remote access to judicial archives [
]. In so doing,
the justice system will see that the majority of the activities in its remit can be performed
using IT systems.
Equally important, to provide an adequate response to major emergencies, particularly
to epidemics of mostly unknown infectious agents, it is essential to seek the input of
all scientific disciplines, especially that of legal medicine. In this regard, it is useful to
reiterate the value of autopsies from a legal and, more importantly, scientific and clinical
point of view in identifying causes of death and in contributing to the reconstruction of
physiopathological pathways that lead to death. This approach may provide determining
scientific information to find possible therapeutic options that would otherwise have been
impossible to obtain [
]. In order to do that, methodology and adherence to strict
protocols in all analyses and activities are required [86].
Ultimately, Italy must adopt a proactive mentality towards these and other crises if it
is to be prepared and scientifically equipped to handle future major emergencies.
4. Conclusions
The COVID-19 pandemic has highlighted several pitfalls in the National Health Ser-
vice in Italy and, more generally, in Western countries that have had to handle and find
extemporaneous solutions to this unforeseen event (e.g., temporary recruitment of physi-
cians and nurses, construction of new departments and even new hospitals, adaptation of
existing facilities, and procurement of PPE). As a result, the health services have been faced
with ethical dilemmas such as deciding who to treat considering the shortage of resources
and inability to ensure all patients receive the necessary intensive care treatment [
dilemmas which Western–particularly the Italian–health services did not envisage having
to face again. In that sense, having a clear understanding of the ethical principles that
govern medical actions means distributive justice, nonmaleficence, respect for patient
autonomy and dignity regardless of their degree of vulnerability, and confidentiality of
medical data in order to make the most appropriate decisions for patients [87,88].
Initially, public opinion was in favor of instituting a legal shield to protect physicians,
but the provision encountered numerous obstacles, abroad as well as in Italy, and to date
has not been approved. Clarification is necessary since it is proper to safeguard healthcare
professionals who have been forced to serve in dramatic conditions (shortage of PPE, lack
of knowledge regarding the etiopathogenesis of the infection, lack of tried-and-tested
treatments) but also to recognize organizational and medical flaws that have de facto
exacerbated the situation.
The current pandemic has led to profound changes in the lives of individuals and
healthcare professionals, brought to light weaknesses in the more developed health services,
Healthcare 2021,9, 17 9 of 13
and called into question many healthcare policy decisions that have been made in recent
decades. There are obvious limits to this study as many articles have been published in
recent months and, therefore, offering a complete and up-to-date review of the literature
presents a challenge. Although not all areas of pandemic-related risks can be mentioned,
this article has analyzed and explored strategies for mitigating risks associated with the
dissemination of the infection in various key sectors in the administration of public services
for immediate application. In addition, it has highlighted programs that may aid the
National Health Service such as PBM, particularly important in Western countries with an
aged population. Some countries have already implemented praiseworthy organizational
strategies: for example, Australia has put in place an extensive PBM program, such that has
facilitated a 60% reduction in the use of red blood cells [
]. These results show that from
a medical point of view, some countries are more prepared than Italy to handle a major
emergency. It must be said, however, that other European countries have encountered
similar problems to Italy [94].
In addition to all the issues discussed in this article, the future will present other issues
in connection with the development of a vaccine. It seems that at least one vaccine will be
available from January 2021 and nationwide distribution will soon commence. This may
create further problems in that the probability of procuring sufficient doses for the entire
population is remote, meaning difficult decisions will need to be made in terms of who
to prioritize. Moreover, additional vaccines may become available in the coming months,
resulting in a diversified vaccination campaign due to the particular characteristics of each
product in terms of efficacy and protection time. The health authorities will need to weigh
these elements carefully, providing full decisional transparency. The public should also be
apprised of these decisions by means of an information campaign in order to maximize
voluntary participation in the vaccination drive.
Author Contributions:
Conceptualization, M.B., M.T.A., A.F.; writing—original draft preparation,
M.B., M.T.A., A.F.; writing—review and editing, A.A., G.D.M., B.D.P.; supervision, A.A., G.D.M.,
B.D.P. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement:
The datasets used during the current study are available from the
corresponding author upon reasonable request.
Conflicts of Interest:
The authors declare that they have no competing interests.The authors declare
no conflict of interest.
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... This has further increased potential litigation within hospitals. It was originally thought that some sort of "immunity" for healthcare workers during the pandemic should be provided [113,114]. In the United States, the American Medical Association (AMA) proposed that healthcare professionals working against SARS-CoV-2 infection be protected from any liability. ...
... Many healthcare workers have worked in unfamiliar environments, in several cases, carrying out new tasks, trying to cope with an unprecedented workload in a general context with a lack of knowledge about the virus. This scenario exposed healthcare workers to an increase in complaints about the treatment provided in these circumstances, and conflicting arguments about how these should be handled within the criminal, civil and regulatory systems [113]. In addition, with the start of the vaccination campaign, new responsibilities arose for health workers employed in these activities, with new risks of liability [128]. ...
Full-text available
During the COVID-19 pandemic, forensic sciences, on the one hand, contributed to gaining knowledge about different aspects of the pandemic, while on the other hand, forensic professionals were called on to quickly adapt their activities to respond adequately to the changes imposed by the pandemic. This review aims to clarify the state of the art in forensic medicine at the time of COVID-19, discussing the following: the influence of external factors on forensic activities, the impact of autopsy practice on COVID-19 and vice-versa, the persistence of SARS-CoV-2 RNA in post-mortem samples, forensic personnel activities during the SARS-CoV-2 pandemic, the global vaccination program and forensic sciences, forensic undergraduate education during and after the imposed COVID-19 lockdown, and the medico-legal implications in medical malpractice claims during the COVID-19 pandemic. The COVID-19 pandemic has greatly influenced different aspects of human life, and, accordingly, the practical activities of forensic sciences that are defined as multidisciplinary, involving different expertise. Indeed, the activities are very different, including crime scene investigation (CSI), external examination, autopsy, and genetic and toxicological examinations of tissues and/or biological fluids. At the same time, forensic professionals may have direct contact with subjects in life, such as in the case of abuse victims (in some cases involving children), collecting biological samples from suspects, or visiting subjects in the case of physical examinations. In this scenario, forensic professionals are called on to implement methods to prevent the SARS-CoV-2 infection risk, wearing adequate PPE, and working in environments with a reduced risk of infection. Consequently, in the pandemic era, the costs involved for forensic sciences were substantially increased.
... Given the increasing connectedness of the world's population, climate change, and the increasing encroachment of human populations on wildlife habitats, the emergence of another infection with global effects is likely. Knowledge derived from the COVID-19 pandemic can be fruitful in response to emerging infections in the future [49,50]. ...
Full-text available
To date, the impact of the COVID-19 pandemic on the world's health, economics and politics is still heavy, and efforts to mitigate virus transmission have caused remarkable disruption. From the early onset of the pandemic, generated by SARS-CoV-2 spread, the scientific community was aware of its impact on vulnerable individuals, including pregnant women. The purpose of this paper is to highlight scientific pitfalls and ethical dilemmas emerging from management of severe respiratory distress in pregnant women in order to add evidence to this topic through an ethical debate. In the here-presented paper, three cases of severe respiratory syndrome are analyzed. No specific therapeutic protocol was available to guide physicians in a cost-benefit balance, and unequivocal conduct was not a priori suggested from scientific evidence. However, vaccines' advent, viral variants lurking on the horizon and other possible pandemic challenges make it necessary to maximize the experience gained through these difficult years. Antenatal management of pregnancies complicated by COVID-19 infection with severe respiratory failure is still heterogeneous and ethical concerns must be pointed out.
... Vaccine intention was higher in male subjects, the elderly, and medical doctors, while female subjects, younger workers, nurses, and auxiliary health personnel showed higher rates of hesitation. In previous studies, the vaccine acceptance rate was related to previous vaccination habits and confidence in vaccine efficacy rather than fear of the negative health consequences of vaccination [20][21][22][23]. In a recent scoping review, intention to be vaccinated was reported to range between 27 and 77% among HCWs. ...
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Background: Hesitancy remains one of the major hurdles to vaccination, regardless of the fact that vaccines are indisputable preventive measures against many infectious diseases. Nevertheless, vaccine hesitancy or refusal is a growing phenomenon in the general population as well as among healthcare workers (HCWs). Many different factors can contribute to hesitancy to COVID-19 vaccination in the HCWs population, including socio-demographic characteristics (female gender, low socio-economical status, lower age), individual beliefs regarding vaccine efficacy and safety, as well as other factors (occupation, knowledge about COVID-19, etc.). Understanding the determinants of accepting or refusing the COVID-19 vaccination is crucial to plan specific interventions in order to increase the rate of vaccine coverage among health care workers. Methods: We conducted a cross-sectional online survey on HCWs in seventeen Italian regions, between 30 June and 4 July 2021, in order to collect information about potential factors related to vaccine acceptance and hesitancy. Results: We found an overall vaccine uptake rate of 96.4% in our sample. Acceptance was significantly related to job task, with physicians showing the highest rate of uptake compared to other occupations. At univariate analysis, the HCWs population's vaccine hesitancy was significantly positively associated with fear of vaccination side effects (p < 0.01), and negatively related to confidence in the safety and efficacy of the vaccine (p < 0.01). Through multivariate analysis, we found that only the fear of possible vaccination side effects (OR: 4.631, p < 0.01) and the confidence in vaccine safety and effectiveness (OR: 0.35 p < 0.05) remained significantly associated with hesitancy. Conclusion: Action to improve operator confidence in the efficacy and safety of the vaccine should improve the acceptance rate among operators.
... Before the pandemic, it was estimated that about 11% of nurses and from 20% to 40% of physicians suffered from burnout [6,7]. The COVID-19 pandemic seems to have exacerbated this issue due to repeated exposure to life-threatening situations, fear of contagion, shift overload and changes in work organization [8,9]. The results of longitudinal studies and the comparison between the estimates of the studies performed before and during the pandemic show a high prevalence and a marked increase of the levels of anxiety, with estimates from studies performed during the pandemic ranging from 22% to 31%, depression (from 17% to 36%), PTSD symptoms (from 13% to 37%) and burnout (from 36% to 52%) [10][11][12][13][14][15][16][17]. ...
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It is unclear if the factor structure of the questionnaires that were employed by studies addressing the impact of COVID-19 on the mental health of Healthcare Workers (HCW) did not change due to the pandemic. The aim of this study is to assess the factor structure and longitudinal measurement invariance of the Maslach Burnout Inventory (MBI) and the factor structure of the General Health Questionnare-12 (GHQ-12), PTSD Checklist for DSM-5-Short Form (PCL-5-SF), Connor-Davidson Resilience Scale-10 (CD-RISC-10) and Post-Traumatic Growth Inventory-Short Form (PTGI-SF). Out of n = 805 HCWs from a University hospital who responded to a pre-COVID-19 survey, n = 431 were re-assessed after the COVID-19 outbreak. A Confirmatory Factor Analysis (CFA) on the MBI showed adequate fit and good internal consistency only after removal of items 2, 6, 12 and 16. The assumptions of configural and metric longitudinal invariance were met, whereas scalar longitudinal invariance did not hold. CFAs and exploratory bifactor analyses performed using data from the second wave confirmed that the GHQ-12, the PCL-5-SF, the PTGI-SF and the CD-RISC-10 were unidimensional. In conclusion, we found support for a refined version of the MBI. The comparison of mean MBI values in HCWs before and after the pandemic should be interpreted with caution.
... Undoubtedly, the COVID-19 epidemic has changed the medical practice and accelerated the introduction and development of telemedicine [47]. ...
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Background: The digital revolution is redesigning the healthcare model, and telemedicine offers a good example of the best cost-effectiveness ratio. The COVID-19 pandemic has catalysed the use of the telemedicine. The aim of this review is to describe and discuss the role and the main applications of telemedicine in the ophthalmic clinical practice as well as the related medico-legal aspects. Methods: 45 original articles and 5 reviews focused on this topic and published in English language from 1997 and 2021 were searched on the online databases of Pubmed, Scopus, Web of Sciences and Embase, by using the following key words: "telemedicine", "privacy", "ophthalmology", "COVID-19" and "informed consent". Results: Telemedicine is able to guarantee patient care using information and communication technologies. Technology creates an opportunity to link doctors with the aim of assessing clinical cases and maintaining high standards of care while performing and saving time as well. Ophthalmology is one of the fields in which telemedicine is most commonly used for patient management. Conclusions: Telemedicine offers benefits to patients in terms of saving time and costs and avoiding physical contact; however, it is necessary to point out significant limitations such as the absence of physical examinations, the possibility of transmission failure and potential violations of privacy and confidentiality.
... The quality of workplace lighting is important, and there is evidence that poor lighting may be associated with headaches [15]. A high frequency of headaches has been observed among healthcare workers during the COVID-19 pandemic, which could be caused by acute infection [16][17][18] or its long-term consequences [19,20], but also possibly due to the use of face masks [21,22] and excessive psychosocial stress caused by the pandemic [23][24][25]. Psychosocial factors seem to play a significant role in the onset of headaches. ...
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Headache is a very common condition that can have a significant impact on work. This study aimed to assess the prevalence of headaches and their impact on a sample of 1076 workers from 18 small companies operating in different sectors. The workers who volunteered to participate were asked to fill in the Headache Impact Test-6 (HIT-6) and answer questions designed to assess stressful and traumatic factors potentially associated with headaches. The volunteers subsequently underwent a medical examination and tests for diagnosing metabolic syndrome. Out of the 1044 workers who completed the questionnaire (participation rate = 97%), 509 (48.8%) reported suffering from headaches. In a multivariate logistic regression model, female gender, recent bereavement, intrusive leadership, and sleep problems were significantly associated with headaches. In univariate logistic regression models, headache intensity was associated with an increased risk of anxiety (OR 1.10; CI95% 1.09; 1.12) and depression (OR 1.09; CI95% 1.08; 1.11). Headache impact was also associated with the risk of metabolic syndrome (OR 1.02; CI95% 1.00, 1.04), obesity (OR 1.02, CI95% 1.01; 1.03), and reduced HDL cholesterol (OR 1.03; CI95% 1.01; 1.04). The impact of headache calls for intervention in the workplace not only to promote a prompt diagnosis of the different forms of headaches but also to improve work organization, leadership style, and the quality of sleep.
... However, it was only during the COVID-19 pandemic that the phenomenon reached unprecedented proportions. In the case of Italy, whose northern regions have been dramatically affected by the effects of the COVID-19 pandemic, with observed shortages of resources [6], it is estimated that there must have been an excess of 47,490 deaths between February and May 2020 alone [7]. In Belgium [8], between 20 March and 28 April, excess deaths are estimated at 7917, while in Portugal, excess deaths estimates between March 1 and April 22 range from 2400 to 4000 deaths [9]. ...
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The issue whether official Polish COVID‑19 death statistics correctly reflect the actual number of deaths is a contentious issue in public discourse and an important policy-wise question in Poland although it has not been the subject of thorough research so far. There had been clearly elevated excess mortality—5100 (death rate of 2.3 per 10,000) during the first wave, 77,500 (21.0 per 10,000) during the second one, and 48,900 (13.5 per 10,000) in the third. This study finds that during the second and the third pandemic wave, our data on excess mortality will match very well the somewhat belatedly officially reported COVID‑19 deaths if we assume that only 60% of cases were officially detected. Based on principal component analysis of death timing, except for the age bracket below 40, where COVID‑19 deaths calculated on the basis of our model explain 55% of excess mortality, for the remaining age groups, combined COVID‑19 deaths explain 95% of excess mortality. Based on the share of excess mortality attributable to COVID‑19 during the second wave, this infection in Poland caused the death of 73,300 people and not of 37,600 as officially reported. The third wave caused 46,200 deaths instead of the reported 34,700. The first wave was, indeed, as officially reported, very mild, and the number of excess deaths was too low to be used to calculate COVID‑19 deaths directly. However, assuming that the detection rate remained comparable to the average in subsequent waves, we can set the number of deaths at 3500 instead of the reported 2100.
... Since the initial outbreak was reported, COVID-19 has been identified as a public health issue and has caused millions of infections and deaths globally [1][2][3][4]. However, there is a broad agreement that eliminating the virus is no longer feasible [5][6][7]. ...
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BACKGROUND The COVID-19 pandemic has spread globally in a short period of time. It is known that antibody (nAb) level can effectively predict vaccine efficacy, which leads to the exploration of vaccine trials for efficacy assessment. Thus, the current study aimed to develop a platform to quantify nAb levels faster, at lower cost, and with better efficiency. MATERIAL AND METHODS A total of 69 sera samples were collected for the research, 28 of which were from unvaccinated participants. The other 27 samples and the remaining 14 samples were from the participants who had received the first and second dose, respectively, of AZ vaccine 1 month before. With cPass assays (Genscript cPass nAb ELISA assay) used as a criterion standard and lateral flow immunoassay kit (Healgen Scientific - LFIA test kit) coupled with a spectrometer (LFIA+S) for checking each specimen, we aimed to detect the presence of neutralizing antibodies in sera and to confirm the relationship between the inhibition rate from cPass assays and the nAb index from the LFIA+S. RESULTS Data analysis of the research were taken from the certified ELISA and LFIA+S, which indicated a high consistency (Pearson's r =0.864; ICC=0.90138) between the 2 methods. CONCLUSIONS The dataset demonstrated that LFIA+S was affordable, had a strong correlation with results of the cPass nAbs detection kit, and has potential clinical applications, with an exclusive feature that allows non-experts to use it with ease. It is believed that the proposed platform can be promoted in the near future.
Introduction: The COVID-19 pandemic has shown the importance of non-specific measures of infectious disease prevention, including the use of respiratory protective equipment. Despite the improvement in the epidemiological situation and gradual lifting of public health restrictions, some people keep wearing face masks. Objective: To analyze the use of respiratory protective equipment in accordance with COVID-19 face mask requirements and after the end of the mask mandate among medical students in Moscow. Materials and methods: The questionnaire-based survey was conducted in two stages in March 2021 and in March–April 2022 among 988 and 830 third year students of the Institute of Clinical Medicine, Sechenov University, respectively, to collect data on socio-demographic characteristics, the practice of wearing face masks in public places, and the incentives to use them. The observational study was carried out in March 2022 among 816 Russian and 96 foreign students by counting those wearing face masks in the classrooms. Results: We established that 97.5 % of the respondents used respiratory protective equipment during the period of restrictive public health measures. The main reasons for doing that were a mask mandate due to coronavirus and the necessity of personal contacts with other people. The survey showed that masks were most often used in health facilities, supermarkets, pharmacies, subway, and at the university. During the first two weeks after abolishing mandatory wearing of face masks, 18.3 % of all the respondents continued their use, mainly out of concern for other people’s health, of whom 9.9 % and 89.6 % were Russian and foreign medical students, respectively. The second survey demonstrated that 7.2 % of the Russian medical students kept wearing masks in some settings later on. In case of yet another increase in the COVID-19 incidence, 97.6 % of the respondents intend to use respiratory protective equipment and 74.7 % of them plan to recommend this preventive measure to their relatives. Conclusions: Medical students continue using respiratory protective equipment after the restrictions are lifted, mainly to protect others.
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BACKGROUND The COVID-19 pandemic has caused many medical, ethical, and medicolegal changes, including constant adjustments in service guidelines. Continuing to revise healthcare regulations and guidelines can potentially cause clinical disputes or medical negligence that require ethical and legal solutions. This study aimed to determine the ethical and medicolegal aspects of the potential factors that cause clinical disputes during the pandemic and provide anticipative solutions to national ethicomedicolegal policies. METHODS A systematic literature search in PubMed, ScienceDirect, ClinicalKey, and Google Scholar was performed using keywords “clinical dispute,” “ethics,” “medicolegal,” “ethicolegal,” and “COVID-19”. The inclusion criteria were articles that contained information on shortage, justice, ethical distribution in intensive care, the possibility of lawsuits and disputes among stakeholders during the pandemic, and stakeholders’ roles in managing the pandemic. Key evidence was analyzed and synthesized following national ethicomedicolegal policies. RESULTS We identified 19 articles from the 4 databases. Based on the literature, the main ethicomedicolegal impact of the COVID-19 pandemic appears in 3 aspects: (1) a shortage of fair and ethical intensive care services with fair and ethical distribution efforts, (2) legal protection for medical personnel from legal charges while providing health services during the pandemic, and (3) the government’s role in managing the pandemic together with the stakeholders involved. CONCLUSIONS Ethicomedicolegal clinical dispute management and its norms require an update, especially when deciding the complexity of COVID-19 service standards. Ethicomedicolegal professionals are needed as intermediaries to manage cases of clinical disputes and to implement fair malpractice criteria in Indonesia.
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Technological advances are changing how forensic laboratories operate in all forensic disciplines, not only digital. Computers support workflow management, enable evidence analysis (physical and digital), and new technology enables previously unavailable forensic capabilities. Used properly, the integration of digital systems supports greater efficiency and reproducibility, and drives digital transformation of forensic laboratories. However, without the necessary preparations, these digital transformations can undermine the core principles and processes of forensic laboratories. Pertinent examples of problems involving technology that have occurred in laboratories are provided, along with opportunities and risk mitigation strategies, based on the authors' experiences. Forensic preparedness concentrating on digital data reduces the cost and operational disruption of responding to various kinds of problems, including misplaced exhibits, allegations of employee misconduct, disclosure requirements, and information security breaches. This work presents recommendations to help forensic laboratories prepare for and manage these risks, to use technology effectively, and ultimately strengthen forensic science. The importance of involving digital forensic expertise in risk management of digital transformations in laboratories is emphasized. Forensic laboratories that do not adopt forensic digital preparedness will produce results based on digital data and processes that cannot be verified independently, leaving them vulnerable to challenge. The recommendations in this work could enhance international standards such as ISO/IEC 17025 used to assess and accredit laboratories.
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Background: Nursing homes provide long-term care and have residential-oriented hospitalizations characterized by medical, nursing, and social-care treatments for a typically geriatric population. In the current emergency phase, the problem of infections in residential structures for the elderly is taking on considerable importance in relation to the significant prevalence rates of COVID-19. Safety improvement strategies: Prevention and control measures for SARS-CoV-2 infection in nursing homes should be planned before a possible outbreak of COVID-19 occurs and should be intensified during any exacerbation of the same. Each facility should identify a properly trained contact person-also external-for the prevention and control of infections, who can refer to a multidisciplinary support committee and who is in close contact with the local health authorities. The contact person should collaborate with professionals in order to prepare a prevention and intervention plan that considers national provisions and scientific evidence, the requirements for reporting patients with symptoms compatible with COVID-19, the indications for the management of suspected, probable or confirmed cases of COVID-19. Discussion: Adequate risk management in residential structures implies the establishment of a coordination committee with dedicated staff, the implementation of a surveillance program for the rapid recognition of the outbreaks, the identification of suitable premises and equipment, the application of universal precautions, the adaptation of care plans to reduce the possibility of contagion among residents, the protection of operators and staff training initiatives.
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On 11th March 2020, the spread of the SARS-CoV-2 virus was declared a pandemic by the World Health Organisation (WHO). Approximately 5.6 million have now been infected and over 350,000 have died. This global public health crisis has since cascaded into a series of challenges for leaders around the world, threatening both the health and economy of populations. This paper attempts to compartmentalise leadership aspects, allowing a closer examination of reports and the analysis of outcomes. The authors are thus enabled to formulate a number of evidence-based recommendations on the de-escalation of restrictions.
Many writers and organizations have postulated that health care facilities and providers may need to implement a “crisis standard of care” to deal with the exigent circumstances associated with the massive influx of patients infected with the novel coronavirus and suffering from COVID‐19. There is a relative scarcity of critical resources, such as intensive care unit beds, emergency department beds, ventilators, personal protective equipment, and medications. Facilities can become overwhelmed. A crisis standard of care can act as a guidepost for rationing supplies and care, should that become necessary. However, that is not without danger. Health care facilities and providers should plan carefully and then act with due deliberation in implementing a crisis standard of care to mitigate or prevent future liability.
This article considers the recent calls to provide doctors with immunity from medical negligence claims arising out of the Covid-19 pandemic. It provides a critical analysis as to the conditions that would need to be considered for such a policy as well as exploring the wider ramifications.
The COVID-19 pandemic has major implications for blood transfusion. There are uncertain patterns of demand, and transfusion institutions need to plan for reductions in donations and loss of crucial staff because of sickness and public health restrictions. We systematically searched for relevant studies addressing the transfusion chain—from donor, through collection and processing, to patients—to provide a synthesis of the published literature and guidance during times of potential or actual shortage. A reduction in donor numbers has largely been matched by reductions in demand for transfusion. Contingency planning includes prioritisation policies for patients in the event of predicted shortage. A range of strategies maintain ongoing equitable access to blood for transfusion during the pandemic, in addition to providing new therapies such as convalescent plasma. Sharing experience and developing expert consensus on the basis of evolving publications will help transfusion services and hospitals in countries at different stages in the pandemic.
During the Covid-19 pandemic, many countries around the world are considering whether and how to provide liability protection to front-line healthcare staff. The guiding principle of liability protection for physicians and others is to ensure that, in a serious emergency situation, health professionals can devote themselves exclusively to their work and to patient care, without the fear of future claims for unforeseeable, but above all unavoidable, injury, loss and damage caused by their conduct. Great care is needed to balance the interests and rights of all those involved. Liability protection could have risky consequences with the final result that doctors will not be protected, but institutions such as health facilities will be even if they were in fact responsible for foreseeable and avoidable damage.