Patient Safety Risks Research Articles

Safety walk-round education to develop risk prediction skills of novice health professional students

Introduction: Students in the early years of medical school should learn clinical site risk assessment skills. However, the effect of this training on clinically inexperienced students is not clear, and it is difficult for students to predict risks from a wide range of perspectives. This study aims to develop and implement three patterns of safety walk rounds (SWR) in a class of students with no clinical experience. Methods: Three types of SWR were conducted: (A) 37 students observed a familiar classroom and predicted safety risks; (B) 39 students created a profile of a fictitious student in advance and then used Type A parameters; (C) 100 students participated. First, Type A was conducted as a practice. Next, students observed a hospital and predicted risks. All participants in Types A to C had no clinical experience. We classified all risks into perception, comprehension, and action. Results: For each safety walk-round, there were two types of risk prediction. In Type A, risks such as perception and comprehension were more than 80%. In Types B and C, action risks were 60%. Students had little experience in observing facilities and none at finding safety risks. Conclusion: Each method had a different risk prediction tendency. Combining the methods could enable students to acquire comprehensive skills in assessing hidden environmental patient safety risks.

Clinician Perceptions on the Use of Free-Text Communication Orders.

The aim of this study was to investigate (1) why ordering clinicians use free-text orders to communicate medication information; (2) what risks physicians and nurses perceive when free-text orders are used for communicating medication information; and (3) how electronic health records (EHRs) could be improved to encourage the safe communication of medication information. We performed semi-structured, scenario-based interviews with eight physicians and eight nurses. Interview responses were analyzed and grouped into common themes. Participants described eight reasons why clinicians use free-text medication orders, five risks relating to the use of free-text medication orders, and five recommendations for improving EHR medication-related communication. Poor usability, including reduced efficiency and limited functionality associated with structured order entry, was the primary reason clinicians used free-text orders to communicate medication information. Common risks to using free-text orders for medication communication included the increased likelihood of missing orders and the increased workload on nurses responsible for executing orders. Clinicians' use of free-text orders is primarily due to limitations in the current structured order entry design. To encourage the safe communication of medication information between clinicians, the EHR's structured order entry must be redesigned to support clinicians' cognitive and workflow needs that are currently being addressed via the use of free-text orders. Clinicians' use of free-text orders as a workaround to insufficient structured order entry can create unintended patient safety risks. Thoughtful solutions designed to address these workarounds can improve the medication ordering process and the subsequent medication administration process.

Inpatient patient safety events in vulnerable populations: a retrospective cohort study

BackgroundWidespread attention to structural racism has heightened interest in disparities in the quality of care delivered to racial/ethnic minorities and other vulnerable populations. These groups may also be at increased...

Burnout and Sources of Stress Among Health Care Risk Managers and Patient Safety Personnel During the COVID-19 Pandemic: A Pilot Study.

This study investigates burnout and sources of stress related to the coronavirus disease 2019 (COVID-19) pandemic among a group of health care risk managers/patient safety practitioners. An online survey was used, including the Oldenburg Burnout Inventory (OLBI) and 1 open-ended question: Since the start of the COVID-19 pandemic, what work or non-work-related issues have been causing you the most stress? A total of 31 participants completed the OLBI; 27 answered the open-ended question. Over 70% of participants qualified as burned out. A thematic analysis was used to analyze stressors. Key themes included impacts of social distancing, changing duties and workload, real and potential impacts of the virus (eg, fear of infection for self or others), and financial concerns (personal and organizational). Less common themes included untrustworthy and constantly changing guidance, feeling abused by persons in power, and positive comments about the experience of working during the pandemic. Burnout and pandemic-related stress may be very common in the health care risk management and patient safety workforce. Additional research is required to more robustly estimate the prevalence of burnout in this population. Meanwhile, the sources of stress identified here may aid health care organizations in taking immediate action to protect this vital workforce.

Arterial aneurysm and dissection with systemic vascular endothelial growth factor inhibitors: A review of cases reported to the FDA Adverse Event Reporting System and published in the literature.

The US Food and Drug Administration (FDA) has approved multiple systemic vascular endothelial growth factor (VEGF) inhibitors since 2004 to treat various malignancies. Inhibition of the VEGF signaling pathway can result in impairment of vascular wall integrity through medial degeneration and endothelial dysfunction, potentially resulting in arterial (including aortic) aneurysm/dissection. We performed a postmarketing review to evaluate arterial aneurysm/dissection as a potential safety risk for patients with cancer treated with VEGF inhibitors. We searched the FDA Adverse Event Reporting System (FAERS) database and literature for reports of arterial (including aortic) aneurysm/dissection with VEGF inhibitors currently approved by the FDA for a cancer indication. We identified 240 cases of arterial aneurysm/dissection associated with VEGF inhibitors. The median time to onset of an arterial aneurysm/dissection event from the initiation of a VEGF inhibitor was 94 days (range 1-1955 days). Notably, 22% (53/240) of cases reported fatal outcomes related to arterial aneurysm/dissection. We determined the drug-event association as probable in 15 cases that lacked relevant confounding factors for arterial aneurysm/dissection, which is supported by unremarkable computed tomography (CT) findings prior to starting VEGF inhibitor therapy, despite nondrug-associated background arterial aneurysm/dissection generally demonstrating preexisting arterial abnormalities. FAERS and literature case-level evidence suggests that VEGF inhibitors may have contributed to arterial aneurysm/dissection, as a class effect, based on short onset relative to natural history of disease and biologic plausibility. Cardiovascular and oncology healthcare professionals should be aware of this rare, but life-threatening safety risk associated with VEGF inhibitors.

630 A Multidisciplinary Approach to Decrease Infection using Visual Management

Abstract Introduction Burn patients are at high risk for infection secondary to skin loss from their wounds. These infections come at great risk for patient safety and are known to increase length of stay, morbidity, and mortality. Due to these factors, we used a multidisciplinary approach to maintain the environment in our Regional Burn Center using visual management. The purpose of this project is to improve communication and follow-through between the Environmental Services Team (EVS), Facilities Management department and the Burn Center Team to initiate and complete repair work and improve cleanliness in patient rooms. The goal is to decrease risk for infection from environmental factors through collaboration with multiple departments and improve patient experience and care. Methods Each room in the Burn Center is mapped out on the Visual Management Board (VMB). Anytime a staff member notices that EVS and/or Facilities Management repair work is needed, they can take the appropriate magnet from the board (see legend) and place it on that room square. Unit leadership will round each morning to see what needs are indicated on the board and initiate work orders or communication with designated unit EVS to meet that need. The issues indicated by the magnets will be logged into a printed spreadsheet (placed on VMB). Each day unit leadership will round to facilitate completion of needed work and will place a date of completion on the spreadsheet when that work is finished as well as remove the magnet from the rooms space. Every Monday, Unit leadership will round at the VMB with EVS and Facilities Management Leadership to address any further needs that were unable to be completed at the unit level that need escalated. EVS/Facilities Management will round back with unit leadership when these items are completed. Key Stakeholders 4. Environmental Services Staff (housekeeping) and Leadership 5. Facilities Management (carpentry) Staff and Leadership 6. Burn Unit Staff and Leadership Additional Resources • Legend for needed work • Communication Tracking Tool • Picture of VMB workspace for this project Results Maintenance and daily cleaning improved. Increased staff engagement in facilities issues in each patient room and the autonomy to notify someone and get escalation of issues when needed. Improved communication and collaboration with multidisciplinary teams for increased awareness of unit-based needs and improved patient safety. Conclusions Upon completion of this presentation, learners will be prepared to discuss multidisciplinary ways to collaborate with the partners that support your Burn Center to enforce patient care and safety.

Current Knowledge about Providing Drug-Drug Interaction Services for Patients-A Scoping Review.

Drug–drug interactions (DDIs) pose a major problem to patient safety. eHealth solutions have the potential to address this problem and generally improve medication management by providing digital services for health care professionals and patients. Clinical decision support systems (CDSS) to alert physicians or pharmacists about DDIs are common, and there is an extensive body of research about CDSS for professionals. Information about DDIs is commonly requested by patients, but little is known about providing similar support to patients. The aim of this scoping review was to explore and describe current knowledge about providing digital DDI services for patients. Using a broad search strategy and an established framework for scoping reviews, 19 papers were included. The results show that although some patients want to check for DDIs themselves, there are differences between patients, in terms of demands and ability. There are numerous DDI services available, but the existence of large variations regarding service quality implies potential safety issues. The review includes suggestions about design features but also indicates a substantial knowledge gap highlighting the need for further research about how to best design and provide digital DDI to patients without risking patient safety or having other unintended consequences.

Application of interval-valued triangular fuzzy numbers and their functional to the healthcare problems

Aim. In healthcare field there exist different types of uncertainty due to medical error generated by human and technologies. In general the crisp value generate loss of precision and inaccuracy about result and therefore the available data is not sufficient to assessed clinical process up to desired degree of accuracy. Therefore fuzzy set theory play as an important and advance role in accuracy of results in healthcare related problems. Methods. Here for more accuracy of result, we use functional fuzzy numbers in this paper. This study uses a new fuzzy fault tree analysis for patient safety risk modelling in healthcare. In this paper we will use level (λ, ρ) interval-valued triangular fuzzy number, their functional, t-norm operation and centre of gravity defuzzification method to evaluate fuzzy failure probability and estimate reliability of system. The effectiveness of these methods is illustrated by an example related to healthcare problems and then we analyse the result obtained with the other existing techniques. Tanaka et al.’s approach has been used to give the rank of basic events of the considered problems. Also, we use functional of fuzzy numbers to analyse the change in fuzzy failure probability. Results. The paper examines the application of the failure tree, t-norm and functional fuzzy numbers in the context of interval-valued triangular fuzzy numbers. The research examined two types of healthcare-specific problems and the corresponding defuzzification techniques for the purpose of reliability analysis using the existing methods. The authors concluded that t-norm is not associated with significant accumulation and identified how a functional fuzzy number affects reliability. Similarly, using the V index method, the least critical events were found for each system.

Segurança do paciente na administração da antibioticoterapia em UTI Adulto: Reconhecendo as condições geradoras de risco

Objetivo: Reconhecer as condições geradoras de risco para a segurança do paciente em uma Unidade de Terapia Intensiva Adulto (UTI – A) no processo de administração de antibióticos. Metodologia: estudo observacional descritivo realizado em uma UTI - A, no Rio Grande do Sul. Participaram do estudo dezessete técnicos de enfermagem que prestavam assistência aos pacientes no período de coleta de dados de abril a outubro de 2020, por meio de observação direta da administração de antibióticos. Utilizou-se o instrumento ASPAM - Avaliação da Segurança do Paciente na Administração de Medicamentos para coleta de dados, que avaliou os nove domínios da administração segura de medicação. Os dados foram analisados por meio de estatística descritiva, sendo que as variáveis contínuas foram representadas por média e desvio padrão ou mediana e intervalo interquartílico (IIQ) e as categóricas por frequência relativa e absoluta. Principais resultados: Identificou-se baixa adesão aos cuidados na utilização de materiais e técnicas assépticas, sendo que somente seis (35,3%) profissionais realizaram este cuidado todas as vezes na preparação dos antibióticos. Em relação ao registro certo, apenas três (17,6%) profissionais sempre registraram o horário logo após a administração. Quanto a orientação realizada ao paciente e/ou acompanhante sobre o medicamento administrado, onze (64,7%) profissionais nunca orientaram. Conclusões: as condições geradoras de risco a segurança do paciente na administração da antibioticoterapia estavam principalmente voltadas a baixa adesão dos cuidados quanto a via certa, registro certo e orientação correta. Identificou-se assim necessidades de melhoria tanto de processos assistenciais quanto de capacitação de equipe.

Investigating the relationship between job stress, workload and oxidative stress in nurses

Objectives. Occupational stress and workload are common risk factors among nurses that increase absenteeism, reduce the quality and quantity of patient care, increase care costs and increase the patient safety risk. The relation between these risk factors and oxidative stress levels has not been clearly defined. Methods. This study was conducted with 258 participants (126 nurses as the case group and 132 healthy adults as the control group). Information was collected using a demographic questionnaire, the nurses’ occupational stress scale and the NASA task load index workload questionnaire. Blood samples were taken from the participants and then the levels of malondialdehyde (MDA), superoxide dismutase (SOD), catalase and total antioxidant capacity (TAC) were measured in the serum samples. Independent t tests and one-way analysis of variance were used for statistical analysis. Results. SOD and TAC were significantly higher and MDA was significantly lower among the case group compared to the control group. TAC levels significantly decreased with increased stress. MDA levels showed negative associations with stress and workload. Nurses experience high levels of occupational stress and workload. Conclusion. Biomarkers such as SOD, TAC and MDA are the most important predictors of work stress and overwork in this study.

Telemedicine for Remote Surgical Guidance in Endoscopic Retrograde Cholangiopancreatography: Mixed Methods Study of Practitioner Attitudes.

BackgroundTelemedicine innovations are rarely adopted into routine health care, the reasons for which are not well understood. Teleguidance, a promising service for remote surgical guidance during endoscopic retrograde cholangiopancreatography (ERCP) was due to be scaled up, but there were concerns that user attitudes might influence adoption.ObjectiveOur objective was to gain a deeper understanding of ERCP practitioners’ attitudes toward teleguidance. These findings could inform the implementation process and future evaluations.MethodsWe conducted semistructured interviews with ERCP staff about challenges during work and beliefs about teleguidance. Theoretical constructs from the technology acceptance model (TAM) guided the thematic analysis. Our findings became input to a 16-item questionnaire, investigating surgeons’ beliefs about teleguidance’s contribution to performance and factors that might interact with implementation.ResultsResults from 20 interviews with ERCP staff from 5 hospitals were used to adapt a TAM questionnaire, exchanging the standard “Ease of Use” items for “Compatibility and Implementation Climate.” In total, 23 ERCP specialists from 15 ERCP clinics responded to the questionnaire: 9 novices (<500 ERCP procedures) and 14 experts (>500 ERCP procedures). The average agreement ratings for usefulness items were 64% (~9/14) among experts and 75% (~7/9) among novices. The average agreement ratings for compatibility items were somewhat lower (experts 64% [~9/14], novices 69% [~6/9]). The averages have been calculated from the sum of several items and therefore, they only approximate the actual values. While 11 of the 14 experts (79%) and 8 of the 9 novices (89%) agreed that teleguidance could improve overall quality and patient safety during ERCP procedures, only 8 of the 14 experts (57%) and 6 of the 9 novices (67%) agreed that teleguidance would not create new patient safety risks. Only 5 of the 14 experts (36%) and 3 of the 9 novices (33%) were convinced that video and image transmission would function well. Similarly, only 6 of the 14 experts (43%) and 6 of the 9 novices (67%) agreed that administration would work smoothly. There were no statistically significant differences between the experts and novices on any of the 16 items (P<.05).ConclusionsBoth novices and experts in ERCP procedures had concerns that teleguidance might disrupt existing work practices. However, novices were generally more positive toward teleguidance than experts, especially with regard to the possibility of developing technical skills and work practices. While newly trained specialists were the main target for teleguidance, the experts were also intended users. As experts are more likely to be key decision makers, their attitudes may have a greater relative impact on adoption. We present suggestions to address these concerns. We conclude that using the TAM as a conceptual framework can support user-centered inquiry into telemedicine design and implementation by connecting qualitative findings to well-known analytical themes.

KNOWLEDGE REGARDING PATIENT SAFETY AMONG NURSING STUDENTS AT SELECTED SETTING, LUCKNOW

Patient Safety is a fundamental principle of health care. Burnout among clinicians both nurses and physicians has consistently been linked to patient safety risks, and some studies show that higher number of patients per nurse is correlated with increased risk of burnout among nurses. The high intensity nature of nurses’ work means that nurses themselves are at risk of committing errors while providing routine care. Interruptions have been tied to an increased risk of errors, particularly medication administration errors. In literature less attention has been paid to the perception of patient safety

Analysis of patient safety risk management call data during the COVID-19 pandemic.

On March 11, 2020, the novel coronavirus disease, COVID-19, was declared a pandemic by the World Health Organization (WHO).1 The pandemic evolved rapidly, forcing providers to face previously unconsidered health care delivery scenarios. Medical and dental professionals sought guidance. This article presents an overview of the questions, concerns, and requests physicians and dentists shared with patient safety risk management consultants (PSRMs) at a large medical professional liability company. During the first 5 months of the pandemic, PSRMs handled more than 1200 calls related to COVID-19. Analysis of call data provides insight into front line provider concerns as the pandemic evolved.

Patient Decision Aids Improve Patient Safety and Reduce Medical Liability Risk

Tort-based doctrines of informed consent have utterly failed to assure that patients understand the risks, benefits, and alternatives to the healthcare they receive. Fifty years of experience with the doctrine of informed consent have shown it to be an abject catastrophe. Most patients lack an even minimal understanding of their treatment options. But there is hope. Substantial evidence shows that patient decision aids (PDAs) and shared decision making can bridge the gap between the theory and practice of informed consent. These evidence-based educational tools empower patients to make decisions with significantly more knowledge and less decisional conflict than clinician-patient discussions alone. Unfortunately, despite robust evidence of effectiveness, few U.S. clinicians use PDAs when they deliver healthcare services. This must change. It is time to move PDAs from research to practice, from the lab to the clinic. This Article describes a key tool that can nudge clinicians to use PDAs with their patients: the monetary incentive of a professional liability insurance premium reduction. Medical malpractice insurance companies should offer premium discounts to clinicians who use PDAs. This incentive will spur PDA use. And PDA use will improve patient safety. That benefits both patients and malpractice insurers. TABLE OF CONTENTS I. Introduction II. Unrealized Promise of Patient Decision Aids A. What Are Patient Decision Aids? B. PDAs Are Effective at Empowering Patients C. Too Few Clinicians Use PDAs III. Medical Liability Insurers Should Incentivize Clinicians to Use PDAs by Offering Premium Discounts A. Medical Malpractice Insurers Already Use Premium Discounts to Incentivize Other Risk-Reducing Conduct B. Offering Premium Discounts Will Spur Wider PDA Uptake IV. PDAs Reduce Liability Risk from Negligent Nondisclosure Claims. A. Medical Liability Insurers Face Significant Risk Exposure from Negligent Nondisclosure Claims 1. Negligent Nondisclosure Claims Are Common 2. Negligent Nondisclosure Claims Are Expensive to Handle B. Carrots and Shields: Using PDAs Enhances Liability Protection. 1. De Jure Safe Harbor Legal Immunity 2. De Facto Safe Harbor Legal Immunity C. Sticks and Swords: Failing to Use PDAs Increases Liability Risk for Negligent Nondisclosure 1. Disclosure Mandates and Presumptions of Negligence 2. Growing Liability Risk under the Reasonable Patient Disclosure Standard D. Using PDAs Reduces Risk by Improving Documentation V. PDAs Reduce Liability Risk from Other Medical Malpractice Claims A. Medical Liability Insurers Face Significant Risk Exposure from Medical Malpractice Claims B. PDAs Result in Better Outcomes and Fewer Claims C. PDAs Result in More Satisfied Patients Who Bring Fewer Claims VI. Conclusion

Effect of Dialysis Nurses' Perception of Patient Safety Risk Factors and Patient Safety Competency on Safety Nursing Activities

Effect of Dialysis Nurses' Perception of Patient Safety Risk Factors and Patient Safety Competency on Safety Nursing Activities

Hypertension: A new safety risk for patients treated with erenumab.

To identify and analyze postmarketing case reports of elevated blood pressure (BP) associated with erenumab use. A retrospective analysis of postmarketing (spontaneous) case reports of erenumab-associated elevated BP submitted to the FDA Adverse Event Reporting System from May 17, 2018 through April 30, 2020. A case of elevated BP was defined as (a) an initiation of a pharmacological intervention or emergency department visit or hospitalization for emergent de novo or worsening of preexisting hypertension, or (b) BP measurement of ≥140mmHg systolic or ≥90mmHg diastolic with or without baseline BP measurement reported. Reports of elevated BP associated with erenumab use were analyzed for baseline and demographic information, latency, drug-event causal association, and clinical outcome. Sixty-one cases of elevated BP were identified, 86% (49/57) were women and the median age was 56 [range 24-88] years. Forty-one cases were associated with a serious outcome per regulatory criteria, including seven that specified hospitalization. No case reported an outcome of death. The median systolic BP increase was 39 (interquartile range (IQR) 32, 59) mmHg and median diastolic BP increase was 28 (IQR 18, 41) mmHg. A total of 27/61 (44%) cases reported treatment for elevated BP (i.e., pharmacologic intervention or emergency department visit/hospitalization). Elevated BP occurred most frequently (28/61, 46%) within a week of the first dose of erenumab. Nineteen cases (19/61, 31%) reported a history of preexisting hypertension. This case series suggest an association between elevated BP and use of erenumab. In light of our findings, the erenumab (Aimovig) prescribing information was amended to include hypertension in the Warnings and Precautions section.

Pros and cons of eHealth: A systematic review of the literature and observations in Denmark.

Objectives:The main objectives of this article are to systematically review the recent literature on patient safety in relation to the use of eHealth and to investigate how the Danish authorities supervise private eHealth clinics with regard to patient safety.Methods:Original studies reporting the association between patient safety and the use of eHealth as a means of communication between patients and healthcare providers were included. Four literature databases were searched for English-language articles reporting results from cohort studies and clinical trials, published from 2015 until March 2021. Moreover, registered private eHealth clinics in Denmark were evaluated with reference to a recent national audit of patient safety issues in eHealth.Results:The literature search retrieved four intervention studies. The studies did not identify any particular patient safety risks associated with the use of eHealth. Many different authorized healthcare providers (preferably, doctors) apply eHealth in various contexts. eHealth is being used as the only form of contact between the healthcare provider and the patient, as a supplement to patient visitations in an outpatient clinic, or as a tool for communicating between two or more healthcare providers. The regulation of eHealth involves patient safety issues but also has interfaces to marketing, IT systems, and infrastructure. Supervision of eHealth includes the organization of clinics, handling patient charts, prescription medicine, patient legal rights, and patient transition. However, there are many interfaces in the division of responsibilities among the various governmental players.Conclusion:eHealth is being used increasingly and in many settings, although recently published intervention studies investigating patient safety issues by the use of eHealth are limited. A structured and continuous governmental control and regulation of patient safety in relation to the use of eHealth is warranted.

Assessment of community pharmacists' communication and comfort levels when interacting with Deaf and hard of hearing patients.

Background:Deaf and hard of hearing patients who use sign language face considerable communication barriers while accessing pharmacy services. Low comfort-levels between community pharmacists and Deaf and hard of hearing patients result in poor interactions and increase patient safety risks.Objective:1) To examine the way community pharmacists interact with Deaf and hard of hearing patients in Malaysia, and their level of comfort in such interactions. 2) To examine how comfort-levels vary by the preferred communication methods, resources and employer support.Methods:This cross-sectional study was conducted among registered community pharmacists practicing in Malaysia. Questionnaire items included comfort-levels of community pharmacists when interacting with Deaf and hard of hearing patients, used and preferred communication methods, necessary resources, and perceived employer’s level of support. Based on the list of registered pharmacies, the questionnaire with a pre-paid return envelope was mailed out while pharmacies close to the university were approached in person. This questionnaire was distributed online using Google Form. Comparisons between comfort-levels and study parameters were analyzed using independent t-tests and ANOVA.Results:A total of 297 community pharmacists responded (response rate 29.2%). Higher comfort-levels were reported in those who had received between 1 to 5 prescriptions as compared to those who did not receive prescriptions from Deaf and hard of hearing patients (MD= -0.257, SD=0.104, p=0.042). More than 80% used written information and only 3.4% had used the services of a qualified sign language interpreter throughout their community pharmacist career. Significantly lower comfort-levels (p=0.0004) were reported in community pharmacists who perceived training in sign language as a necessity to interact with Deaf and hard of hearing patients (M=3.6, SD=0.9) versus those who were not interested in sign language training (M=3.8, SD=0.6).Conclusions:The results suggest that community pharmacists were neither extremely comfortable nor averse when interacting with Deaf and hard of hearing patients. The lack of significant findings in terms of comfort-levels may indicate other potential drivers for their choice of communication method when interacting with Deaf and hard of hearing patients.

Role of Patient Safety Incident Reporting Systems in Home Hospitalization

Introduction: The present study aimed to assess the effectiveness of the current hospital-based electronic patient safety incident reporting system (IRS) in the improvement of patient safety in home hospitalization (HH). Materials and Methods: Out of 6381 patient safety reports voluntarily presented by healthcare professionals in a tertiary hospital in Barcelona between 2016 and 2019, all those related to HH were analyzed. They were characterized by incident type, description, risk and year, the ways to get notified, patient’s age, and the results of the analysis. Moreover, falls were classified depending on circumstances. Results: Based on the results, 68 HH incident reports were related to the following factors: use of medication (n=2), procedures (1), patient’s behavior (n=1), and falls (n=64). Regarding the damage degree, the incidents were reported as extreme risk (n=1), high (n=8), moderate (n=27), low (29), and very low risk (n=3). The majority of patients involved in the incidents were more than 60 years old. Out of the reported falls, 8 cases were categorized as high risk, and 32 cases reported health consequences. Moreover, 19 falls from height, 31 cases of falling while sitting or lying, and 30 incidents classified as unknown were identified. Conclusion: Patient safety is a matter of great concern, especially in HH but with some differential features. The IRS can play a peculiar role in minimizing patient safety risks and promoting a safety culture. The results of the present study pointed to some frequent risks and suggested improving opportunities in HH. Nonetheless, further studies are needed to design tailored patient safety interventions in HH, as well as a tailored IRS adapted to this growing setting.

Report From a Virtual Care Task Force

While telehealth has been available for decades, as a result of the COVID-19 pandemic, an unprecedented demand arose for the remote delivery of safe and reliable assessments and treatment recommendations via computers, smart phones, and tablets. Institutions and individual providers needed to accelerate their adoption of virtual care. This ability to provide remote evaluations has helped to protect patients and providers at this time when physical distancing is a priority. This rapid shift to telemedicine has also meant that many providers, with limited experience or training in the virtual delivery of care, were required to adapt to new and unfamiliar technologies as part of their daily practice of medicine. Institutions and individuals have recognized that this sudden and unexpected expansion of virtual care had the potential to increase patient safety risks. Given that telemedicine will remain a mainstay after the COVID-19 pandemic, it will be important to focus on quality and safety issues that are likely to arise but as yet remain to be appreciated. This chapter explores patient safety guidance.