Maintaining routine inpatient safety under prolonged armed conflict: an institutional case study of a frontline civilian hospital

Civilian hospitals operating under prolonged armed conflict must sustain routine inpatient care while repeatedly adapting to changing security conditions. Although previous research has documented attacks on healthcare, infrastructure damage, service disruption, and trauma-related demands, less is known about the organizational safety challenges faced by hospitals that remain operational during recurrent and prolonged threat. This practice-informed institutional case study examined patient safety challenges and adaptive responses in a frontline civilian hospital in northern Israel. The analysis drew on institutional operational materials generated during repeated transitions between routine wards and protected care areas, including multidisciplinary safety and quality rounds, management reviews, incident and near-miss materials, infrastructure assessments, and operational discussions. An inductive and iterative interpretive review was used to identify recurrent cross-cutting patterns across departments, operational phases, and source types. Four interrelated domains were identified: environmental and infrastructural conditions, clinical care processes, workforce and team dynamics, and patient flow and organizational adaptation. Recurrent transitions disrupted established work environments, clinical routines, team configurations, and organizational interfaces. Institutional responses included repeated re-establishment of clinical workspaces and safety-critical infrastructure, reinforcement of core clinical and communication practices, coordination of newly configured teams, and ongoing reorganization of patient flow and support services. Routine inpatient safety during prolonged armed conflict is shaped by interacting environmental, clinical, workforce, and organizational conditions. The contribution of this case lies not in proposing a new patient safety framework, but in showing how established safety domains are repeatedly destabilized and require recurrent adaptation and organizational re-stabilization. These findings may inform preparedness and resilience planning in hospitals operating under comparable conditions, while recognizing that the study did not evaluate the effectiveness of specific adaptations or patient safety outcomes.