Peter D. Mills PhD, MS (is Director, US Department of Veterans Affairs (VA) National Center for Patient Safety Field Office, White River Junction, Vermont, and Clinical Professor of Psychiatry, Geisel School of Medicine at Dartmouth.), Anne Tomolo MD, MPH (is Co-Director of the Chief Resident for Quality and Safety Program and Advanced Fellowship in Patient Safety Program, VA National Center for Patient Safety, and Associate Professor, Department of Medicine, Emory University School of Medicine.), Edward E. Yackel DNP, FNP-C, FAANP (is Executive Director, VA National Center for Patient Safety, and Adjunct Clinical Instructor, Department of Health Behavior and Biological Sciences, University of Michigan. Please address correspondence to Peter D. Mills)
{"title":"退伍军人健康管理中涉及远程医疗的不良事件","authors":"Peter D. Mills PhD, MS (is Director, US Department of Veterans Affairs (VA) National Center for Patient Safety Field Office, White River Junction, Vermont, and Clinical Professor of Psychiatry, Geisel School of Medicine at Dartmouth.), Anne Tomolo MD, MPH (is Co-Director of the Chief Resident for Quality and Safety Program and Advanced Fellowship in Patient Safety Program, VA National Center for Patient Safety, and Associate Professor, Department of Medicine, Emory University School of Medicine.), Edward E. Yackel DNP, FNP-C, FAANP (is Executive Director, VA National Center for Patient Safety, and Adjunct Clinical Instructor, Department of Health Behavior and Biological Sciences, University of Michigan. Please address correspondence to Peter D. Mills)","doi":"10.1016/j.jcjq.2024.12.002","DOIUrl":null,"url":null,"abstract":"<div><h3>Background</h3><div>Telehealth involves providing health care remotely using communication tools such as telephone, video, and remote patient monitoring. Research on telehealth has shown many benefits, including improved access to care and reduced costs, and drawbacks, including delays in care, breakdowns in communication, and missed diagnoses. The use of telehealth nationally, including in the Veterans Health Administration (VHA), expanded dramatically during the COVID-19 pandemic. Despite its increased use, few studies have described adverse events or the role of patient safety in the provision of telehealth.</div></div><div><h3>Methods</h3><div>The authors looked at all reports of adverse events and close calls in the VHA involving the use of telehealth between October 1, 2022, and February 2, 2023, and coded each case for the location of the event, type of event, and causes.</div></div><div><h3>Results</h3><div>A total of 145 reports met criteria for review. Most events occurred in primary care, outpatient behavioral health, and radiology, with delays in care, medication errors, and equipment problems being common types. Most reported events did not cause harm; 45 cases were identified as an unsafe condition, 37 as a close call, and 15 as causing some harm to the patient. There were 3,609,105 telehealth episodes of care during this time, resulting in a reporting rate of 4.02 per 100,000 episodes of care and 0.42 reports of harm per 100,000 episodes of care.</div></div><div><h3>Conclusion</h3><div>The most frequent telehealth-related events were delays in care, medication errors, and equipment issues, and most events were not unique to this modality. Further research is needed to characterize safety events unique to telehealth to better define parameters for patient safety activities. Recommendations to reduce errors include ongoing provider training, human factors analysis of telehealth processes, simplifying processes and procedures for providers and patients to get help for technical or knowledge deficits in real time, and examining the business rules for telehealth care.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 486-492"},"PeriodicalIF":2.4000,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Adverse Events Involving Telehealth in the Veterans Health Administration\",\"authors\":\"Peter D. Mills PhD, MS (is Director, US Department of Veterans Affairs (VA) National Center for Patient Safety Field Office, White River Junction, Vermont, and Clinical Professor of Psychiatry, Geisel School of Medicine at Dartmouth.), Anne Tomolo MD, MPH (is Co-Director of the Chief Resident for Quality and Safety Program and Advanced Fellowship in Patient Safety Program, VA National Center for Patient Safety, and Associate Professor, Department of Medicine, Emory University School of Medicine.), Edward E. Yackel DNP, FNP-C, FAANP (is Executive Director, VA National Center for Patient Safety, and Adjunct Clinical Instructor, Department of Health Behavior and Biological Sciences, University of Michigan. Please address correspondence to Peter D. Mills)\",\"doi\":\"10.1016/j.jcjq.2024.12.002\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<div><h3>Background</h3><div>Telehealth involves providing health care remotely using communication tools such as telephone, video, and remote patient monitoring. Research on telehealth has shown many benefits, including improved access to care and reduced costs, and drawbacks, including delays in care, breakdowns in communication, and missed diagnoses. The use of telehealth nationally, including in the Veterans Health Administration (VHA), expanded dramatically during the COVID-19 pandemic. Despite its increased use, few studies have described adverse events or the role of patient safety in the provision of telehealth.</div></div><div><h3>Methods</h3><div>The authors looked at all reports of adverse events and close calls in the VHA involving the use of telehealth between October 1, 2022, and February 2, 2023, and coded each case for the location of the event, type of event, and causes.</div></div><div><h3>Results</h3><div>A total of 145 reports met criteria for review. Most events occurred in primary care, outpatient behavioral health, and radiology, with delays in care, medication errors, and equipment problems being common types. Most reported events did not cause harm; 45 cases were identified as an unsafe condition, 37 as a close call, and 15 as causing some harm to the patient. There were 3,609,105 telehealth episodes of care during this time, resulting in a reporting rate of 4.02 per 100,000 episodes of care and 0.42 reports of harm per 100,000 episodes of care.</div></div><div><h3>Conclusion</h3><div>The most frequent telehealth-related events were delays in care, medication errors, and equipment issues, and most events were not unique to this modality. Further research is needed to characterize safety events unique to telehealth to better define parameters for patient safety activities. Recommendations to reduce errors include ongoing provider training, human factors analysis of telehealth processes, simplifying processes and procedures for providers and patients to get help for technical or knowledge deficits in real time, and examining the business rules for telehealth care.</div></div>\",\"PeriodicalId\":14835,\"journal\":{\"name\":\"Joint Commission journal on quality and patient safety\",\"volume\":\"51 7\",\"pages\":\"Pages 486-492\"},\"PeriodicalIF\":2.4000,\"publicationDate\":\"2025-07-01\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Joint Commission journal on quality and patient safety\",\"FirstCategoryId\":\"1085\",\"ListUrlMain\":\"https://www.sciencedirect.com/science/article/pii/S1553725024003829\",\"RegionNum\":0,\"RegionCategory\":null,\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q2\",\"JCRName\":\"HEALTH CARE SCIENCES & SERVICES\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Joint Commission journal on quality and patient safety","FirstCategoryId":"1085","ListUrlMain":"https://www.sciencedirect.com/science/article/pii/S1553725024003829","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"HEALTH CARE SCIENCES & SERVICES","Score":null,"Total":0}
Adverse Events Involving Telehealth in the Veterans Health Administration
Background
Telehealth involves providing health care remotely using communication tools such as telephone, video, and remote patient monitoring. Research on telehealth has shown many benefits, including improved access to care and reduced costs, and drawbacks, including delays in care, breakdowns in communication, and missed diagnoses. The use of telehealth nationally, including in the Veterans Health Administration (VHA), expanded dramatically during the COVID-19 pandemic. Despite its increased use, few studies have described adverse events or the role of patient safety in the provision of telehealth.
Methods
The authors looked at all reports of adverse events and close calls in the VHA involving the use of telehealth between October 1, 2022, and February 2, 2023, and coded each case for the location of the event, type of event, and causes.
Results
A total of 145 reports met criteria for review. Most events occurred in primary care, outpatient behavioral health, and radiology, with delays in care, medication errors, and equipment problems being common types. Most reported events did not cause harm; 45 cases were identified as an unsafe condition, 37 as a close call, and 15 as causing some harm to the patient. There were 3,609,105 telehealth episodes of care during this time, resulting in a reporting rate of 4.02 per 100,000 episodes of care and 0.42 reports of harm per 100,000 episodes of care.
Conclusion
The most frequent telehealth-related events were delays in care, medication errors, and equipment issues, and most events were not unique to this modality. Further research is needed to characterize safety events unique to telehealth to better define parameters for patient safety activities. Recommendations to reduce errors include ongoing provider training, human factors analysis of telehealth processes, simplifying processes and procedures for providers and patients to get help for technical or knowledge deficits in real time, and examining the business rules for telehealth care.
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