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Competing Interests: Declaration of competing interests N/A.

Objective: The objective of this review was to develop a taxonomy of pressures experienced by health services and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies were developed from a review of observational studies directly assessing care delivered in a variety of clinical environments., Design: In the first phase, a scoping review of the relevant literature was conducted. In the second phase, pressures and strategies were systematically coded from the included papers, and categorised., Data Sources: Electronic databases (MEDLINE, Embase, CINAHL, PsycInfo and Scopus) and reference lists from recent reviews of the resilient healthcare literature., Eligibility Criteria: Studies were included from the resilient healthcare literature, which used descriptive methodologies to directly assess a clinical environment. The studies were required to contain strategies for managing under pressure., Results: 5402 potential articles were identified with 17 papers meeting the inclusion criteria. The principal source of pressure described in the studies was the demand for care exceeding capacity (ie, the resources available), which in turn led to difficult working conditions and problems with system functioning. Strategies for responding to pressures were categorised into anticipatory and on-the-day adaptations. Anticipatory strategies included strategies for increasing resources, controlling demand and plans for managing the workload (efficiency strategies, forward planning, monitoring and co-ordination strategies and staff support initiatives). On-the-day adaptations were categorised into: flexing the use of existing resources, prioritising demand and adapting ways of working (leadership, teamwork and communication strategies)., Conclusions: The review has culminated in an empirically based taxonomy of pressures and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies could help clinicians and managers to optimise how they respond to pressures and may be used as the basis for training programmes and future research evaluating the impact of different strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Healthcare systems are operating under substantial pressures. Clinicians and managers are constantly having to make adaptations, which are typically improvised, highly variable and not coordinated across teams. This study aimed to identify and describe the types of everyday pressures in intensive care and the adaptive strategies staff use to respond, with the longer-term aim of developing practical and coordinated strategies for managing under pressure., Methods: We conducted qualitative semi-structured interviews with 20 senior multidisciplinary healthcare professionals from intensive care units (ICUs) in 4 major hospitals in the UK. The interviews explored the everyday pressures faced by intensive care staff and the strategies they use to adapt. A thematic template analysis approach was used to analyse the data based on our previously empirically developed taxonomy of pressures and strategies., Results: The principal source of pressure described was a shortage of staff with the necessary skills and experience to care for the increased numbers and complexity of patients which, in turn, increased staff workload and reduced patient flow. Strategies were categorised into anticipatory (in advance of anticipated pressures) and on the day. The dynamic and unpredictable demands on ICUs meant that strategies were mostly deployed on the day, most commonly by flexing staff, prioritisation of patients and tasks and increasing modes of communication and support., Conclusions: ICU staff use a wide variety of adaptive strategies at times of pressure to minimise risk and maintain a reasonable standard of care for patients. These findings provide the foundation for a portfolio of strategies, which can be flexibly employed when under pressure. There is considerable potential for training clinical leaders and teams in the effective use of adaptive strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Acute inpatient mental health services report high levels of safety incidents. The application of patient safety theory has been sparse, particularly concerning interventions that proactively seek patient perspectives., Objective(s): Develop and evaluate a theoretically based, digital monitoring tool to collect real-time information from patients on acute adult mental health wards about their perceptions of ward safety., Design: Theory-informed mixed-methods study. A prototype digital monitoring tool was developed from a co-design approach, implemented in hospital settings, and subjected to qualitative and quantitative evaluation., Setting and Methods: Phase 1: scoping review of the literature on patient involvement in safety interventions in acute mental health care; evidence scan of digital technology in mental health contexts; qualitative interviews with mental health patients and staff about perspectives on ward safety. This, alongside stakeholder engagement with advisory groups, service users and health professionals, informed the development processes. Most data collection was virtual. Phase 1 resulted in the technical development of a theoretically based digital monitoring tool that collected patient feedback for proactive safety monitoring. Phase 2: implementation of the tool in six adult acute mental health wards across two UK NHS trusts; evaluation via focused ethnography and qualitative interviews. Statistical analysis of WardSonar data and routine ward data involving construction of an hour-by-hour data set per ward, permitting detailed analysis of the use of the WardSonar tool., Participants: A total of 8 patients and 13 mental health professionals participated in Phase 1 interviews; 33 staff and 34 patients participated in Phase 2 interviews., Interventions: Patients could use a web application (the WardSonar tool) to record real-time perceptions of ward safety. Staff could access aggregated, anonymous data to inform timely interventions., Results: Coronavirus disease 2019 restrictions greatly impacted the study. Stakeholder engagement permeated the project. Phase 1 delivered a theory-based, collaboratively designed digital tool for proactive patient safety monitoring. Phase 2 showed that the tool was user friendly and broadly acceptable to patients and staff. The aggregated safety data were infrequently used by staff. Feasibility depended on engaged staff and embedding use of the tool in ward routines. There is strong evidence that an incident leads to increased probability of further incidents within the next 4 hours. This puts a measure on the extent to which social/behavioural contagion persists. There is weak evidence to suggest that an incident leads to a greater use of the WardSonar tool in the following hour, but none to suggest that ward atmosphere predicts future incidents. Therefore, how often patients use the tool seems to send a stronger signal about potential incidents than patients' real-time reports about ward atmosphere ., Limitations: Implementation was limited to two NHS trusts. Coronavirus disease 2019 impacted design processes including stakeholder engagement; implementation; and evaluation of the monitoring tool in routine clinical practice. Higher uptake could enhance validity of the results., Conclusions: WardSonar has the potential to provide a valuable route for patients to communicate safety concerns. The WardSonar monitoring tool has a strong patient perspective and uses proactive real-time safety monitoring rather than traditional retrospective data review., Future Work: The WardSonar tool can be refined and tested further in a post Coronavirus disease 2019 context., Study Registration: This study is registered as ISRCTN14470430., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128070) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 14. See the NIHR Funding and Awards website for further award information.

Background: Healthcare systems are operating under substantial pressures, and often simply cannot provide the standard of care they aspire to within the available resources. Organisations, managers, and individual clinicians make constant adaptations in response to these pressures, which are typically improvised, highly variable and not coordinated across clinical teams. The purpose of this study was to identify and describe the types of everyday pressures experienced by surgical teams and the adaptive strategies they use to respond to these pressures., Methods: We conducted interviews with 20 senior multidisciplinary healthcare professionals from surgical teams in four major hospitals in the United Kingdom. The interviews explored the types of everyday pressures staff were experiencing, the strategies they use to adapt, and how these strategies might be taught to others., Results: The primary pressures described by senior clinicians in surgery were increased numbers and complexity of patients alongside shortages in staff, theatre space and post-surgical beds. These pressures led to more difficult working conditions (e.g. high workloads) and problems with system functioning such as patient flow and cancellation of lists. Strategies for responding to these pressures were categorised into increasing or flexing resources, controlling and prioritising patient demand and strategies for managing the workload (scheduling for efficiency, communication and coordination, leadership, and teamwork strategies)., Conclusions: Teams are deploying a range of strategies and making adaptations to the way care is delivered. These findings could be used as the basis for training programmes for surgical teams to develop coordinated strategies for adapting under pressure and to assess the impact of different combinations of strategies on patient safety and surgical outcomes., (© 2024. The Author(s).)

Background: This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations., Methods: Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators., Results: Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators., Conclusions: This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts., (© 2023. The Author(s).)

Background: Incident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. There is little empirical evidence about how-in real-world hospital settings-recommendations are generated or judged for effectiveness., Objectives: Our research questions, concerning internal hospital investigations, were as follows: (1) What approaches to incident investigation are used before the generation of recommendations? (2) What are the processes for generating recommendations after a patient safety incident investigation? (3) What are the number and types of recommendations proposed? (4) What criteria are used, by hospitals or study authors, to assess the quality or strength of recommendations made?, Methods: Following PRISMA-ScR guidelines, we conducted a scoping review. Studies were included if they reported data from investigations undertaken and recommendations generated within hospitals. Review questions were answered with content analysis, and extracted recommendations were categorized and counted., Results: Eleven studies met the inclusion criteria. Root cause analysis was the dominant investigation approach, but methods for recommendation generation were unclear. A total of 4579 recommendations were extracted, largely focusing on individuals' behavior rather than addressing deficiencies in systems (<7% classified as strong). Included studies reported recommendation effectiveness as judged against predefined "action" hierarchies or by incident recurrence, which was not comprehensively reported., Conclusions: Despite the ubiquity of incident investigation, there is a surprising lack of evidence concerning how recommendation generation is or should be undertaken. Little evidence is presented to show that investigations or recommendations result in improved care quality or safety. We contend that, although incident investigations remain foundational to patient safety, more enquiry is needed about how this important work is actually achieved and whether it can contribute to improving quality of care., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Non-technical skills (NTS) assessment tools are widely used to provide formative and summative assessment for healthcare professionals and there are now many of them. This study has examined three different tools designed for similar settings and gathered evidence to test their validity and usability., Methods: Three NTS assessment tools designed for use in the UK were used by three experienced faculty to review standardized videos of simulated cardiac arrest scenarios: ANTS (Anesthetists' Non-Technical Skills), Oxford NOTECHS (Oxford NOn-TECHnical Skills) and OSCAR (Observational Skill based Clinical Assessment tool for Resuscitation). Internal consistency, interrater reliability and quantitative and qualitative analysis of usability were analyzed for each tool., Results: Internal consistency and interrater reliability (IRR) varied considerably for the three tools across NTS categories and elements. Intraclass correlation scores of three expert raters ranged from poor (task management in ANTS [0.26] and situation awareness (SA) in Oxford NOTECHS [0.34]) to very good (problem solving in Oxford NOTECHS [0.81] and cooperation [0.84] and SA [0.87] in OSCAR). Furthermore, different statistical tests of IRR produced different results for each tool. Quantitative and qualitative examination of usability also revealed challenges in using each tool., Conclusions: The lack of standardization of NTS assessment tools and training in their use is unhelpful for healthcare educators and students. Educators require ongoing support in the use of NTS assessment tools for the evaluation of individual healthcare professionals or healthcare teams. Summative or high-stakes examinations using NTS assessment tools should be undertaken with at least two assessors to provide consensus scoring. In light of the renewed focus on simulation as an educational tool to support and enhance training recovery in the aftermath of COVID-19, it is even more important that assessment of these vital skills is standardized, simplified and supported with adequate training., (© 2023. Crown.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Introduction: Patient safety problems stemming from healthcare delivery constitute a global public health concern and represent a pervasive barrier to improving care quality and clinical outcomes. However, evidence generation into safety in mental health care, particularly regarding community-based mental health services, has long fallen behind that of physical health care, forming the focus of fewer research publications and developed largely in isolation from the wider improvement science discipline. We aimed to investigate the state of the field, along with key conceptual and empirical challenges to understanding patient safety in community-based mental health care., Methods: A narrative review surveyed the literature to appraise the conceptual obstacles to advancing the science of patient safety in community-based mental health services. Sources were identified through a combination of a systematic search strategy and targeted searches of theoretical and empirical evidence from the fields of mental health care, patient safety and improvement science., Results: Amongst available evidence, challenges in defining safety in the context of community mental health care, evaluating safety in long-term care journeys and establishing what constitutes a 'preventable' safety problem, were identified. A dominant risk management approach to safety in mental health care, positioning service users as the origin of risk, has seemingly prevented a focus on proactive safety promotion, considering iatrogenic harm and latent system hazards., Conclusion: We propose a wider conceptualization of safety and discuss the next steps for the integration and mobilization of disparate sources of 'safety intelligence', to advance how safety is conceived and addressed within community mental health care., Patient and Public Contribution: This paper was part of a larger research project aimed at understanding and improving patient safety in community-based mental health care. Although service users, carers and healthcare professionals were not involved as part of this narrative review, the views of these stakeholder groups were central to shaping the wider research project. For a qualitative interview and focus group study conducted alongside this review, interview topic guides were informed by this narrative analysis, designed jointly and piloted with a consultation group of service users and carers with experience of community-based mental health services for working-age adults, who advised on key questioning priorities., (© 2022 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Heparin is a highly sulfated, hence highly polyanionic, glycosaminoglycan with a repeating disaccharide that contains a hexuronic acid, and it has been used as an anticoagulant clinically for more than half a century. Daily IP injections of small amounts of heparin in the STZ diabetic rat prevented these pathological responses even though the animals sustained hyperglycemic levels of glucose throughout. However, the structural determinant that mediates this activity is not clear. This paper describes our finding that the responses of hyperglycemic dividing mesangial cells to heparin are mediated by its non-reducing terminal trisaccharide and proposes that the non-reducing end tri-saccharide of heparin acts as a scavenger tool to detoxify the glucose toxicity in diabetes., Competing Interests: Conflict of Interest The authors declare that they have no conflicts of interest with the contents of this article.

Introduction: Child Safeguarding Services intervene in situations where a child is at risk of serious emotional or physical harm. The response will vary according to the level of risk, but in serious cases, a child may need to be removed from danger and cared for by foster parents either temporarily or permanently. The number of children being taken into care has increased markedly in recent years in the United Kingdom. Oxfordshire County Council (OCC) is implementing a new approach to the welfare of children (Family Solutions Plus; FSP) in which the focus is to support the whole family and ideally reduce the need for foster care.In this paper, we describe a proposed programme of evaluation to examine the impact of FSP on the time children are in contact with services, the nature of the support provided, experience of children and families, the experience of staff, and longer term outcomes for children, particularly whether they remain within the family or need to be cared for outside the home., Methods and Analysis: A mixed methods approach will be taken in an observational retrospective study of children's social care services. Quantitative research will include descriptive analysis on data routinely collected by OCC, examining the effect on time spent in services, outcomes for children and how these outcomes are mediated by family characteristics and circumstances. Qualitative research will be carried out using individual interviews and focus groups with children, families and staff in the teams providing family safeguarding services to capture their experiences with the new model., Ethics and Dissemination: This project has been registered with the OCC as a service evaluation. The qualitative studies will seek ethical approval from Oxford University Ethics Committee. A local data sharing agreement will govern the transfer of quantitative data. Results will be disseminated through newsletters, community forums, professional publications and conference presentations to national and international audiences., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2022 The Author(s).)

Objective: To describe and disseminate a package of support for parents who care for children with gastrostomies, consisting of a library of videos and resources to support families from referral for gastrostomy surgery, to long-term support at home., Methods: The resources were systematically developed and evaluated by parents, hospital and community-based nurses, paediatricians, a surgeon and researchers., Results: The videos empower families, reduce their anxiety and increase their confidence, providing support throughout the families' journey. Surveys and feedback from parents and clinicians show that the video library is seen as providing clear and comprehensive guidance and is suitable for integration into routine practice. To effectively disseminate these resources across a region, the videos need to be shared widely with relevant community and hospital-based teams, and shared through parent networks. The videos should be viewed as one part of a wider package of training and support, in combination with hands-on-practice and clinical support., Conclusions: The resources described have been developed with and for families. Critically the videos are founded in the lived-experience of families, as well as the expertise of clinicians from community and hospital services. Similar resources are needed to support families performing other types of specialist care. The resources are freely available to any parent or clinical team., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: The COVID-19 pandemic required mental health services around the world to adapt quickly to the new restrictions and regulations put in place to reduce the risk of transmission. As face-to-face contact became difficult, virtual methods were implemented to continue to safely provide mental health care. However, it is unclear to what extent service provision transitioned to telemental health worldwide., Objective: We aimed to systematically review the global research literature on how mental health service provision adapted during the first year of the pandemic., Methods: We searched systematically for quantitative papers focusing on the impact of the COVID-19 pandemic on mental health services published until April 13, 2021, in the PubMed, Embase, medRxiv, and bioXriv electronic bibliographic databases, using the COVID-19 Open Access Project online platform. The screening process and data extraction were independently completed by at least two authors, and any disagreement was resolved by discussion with a senior member of the team. The findings were summarized narratively in the context of each country's COVID-19 Stringency Index, which reflects the stringency of a government's response to COVID-19 restrictions at a specific time., Results: Of the identified 24,339 records, 101 papers were included after the screening process. Reports on general services (n=72) showed that several countries' face-to-face services reduced their activities at the start of the pandemic, with reductions in the total number of delivered visits and with some services forced to close. In contrast, telemental health use rapidly increased in many countries across the world at the beginning of the pandemic (n=55), with almost complete virtualization of general and specialistic care services by the end of the first year. Considering the reported COVID-19 Stringency Index values, the increased use of virtual means seems to correspond to periods when the Stringency Index values were at their highest in several countries. However, due to specific care requirements, telemental health could not be used in certain subgroups of patients, such as those on clozapine or depot treatments and those who continued to need face-to-face visits., Conclusions: During the pandemic, mental health services had to adapt quickly in the short term, implementing or increasing the use of telemental health services across the globe. Limited access to digital means, poor digital skills, and patients' preferences and individual needs may have contributed to differences in implementing and accessing telemental health services during the pandemic. In the long term, a blended approach, combining in-person and virtual modalities, that takes into consideration the needs, preferences, and digital skills of patients may better support the future development of mental health services. It will be required to improve confidence with digital device use, training, and experience in all modalities for both clinicians and service users., (©Caroline Zangani, Edoardo G Ostinelli, Katharine A Smith, James S W Hong, Orla Macdonald, Gurpreet Reen, Katherine Reid, Charles Vincent, Rebecca Syed Sheriff, Paul J Harrison, Keith Hawton, Alexandra Pitman, Rob Bale, Seena Fazel, John R Geddes, Andrea Cipriani. Originally published in JMIR Mental Health (https://mental.jmir.org), 22.08.2022.)

Attention has turned to improving the quality and safety of healthcare within health facilities to reduce avoidable mortality and morbidity. Interventions should be tested in health system environments that can support their adoption if successful. To be successful, interventions often require changes in multiple behaviours making their consequences unpredictable. Here, we focus on this challenge of change at the mesolevel or microlevel. Drawing on multiple insights from theory and our own empirical work, we highlight the importance of engaging managers, senior and frontline staff and potentially patients to explore foundational questions examining three core resource areas. These span the physical or material resources available, workforce capacity and capability and team and organisational relationships. Deficits in all these resource areas may need to be addressed to achieve success. We also argue that as inertia is built into the complex social and human systems characterising healthcare facilities that thought on how to mobilise five motive forces is needed to help achieve change. These span goal alignment and ownership, leadership for change, empowering key actors, promoting responsive planning and procurement and learning for transformation. Our aim is to bridge the theory-practice gap and offer an entry point for practical discussions to elicit the critical tacit and contextual knowledge needed to design interventions. We hope that this may improve the chances that interventions are successful and so contribute to better facility-based care and outcomes while contributing to the development of learning health systems., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Viral suppression (VS) is the hallmark of successful antiretroviral therapy (ART) programmes. We sought to compare clinic retention, virological outcomes, drug resistance and mortality between peri-urban and rural settings in South Africa after first-line ART., Methods: Beginning in July 2014, 1000 (500 peri-urban and 500 rural) ART-naïve patients with HIV were enrolled and managed according to local standard of care. Clinic retention, virological suppression, virological failure (VF), genotypic drug resistance and mortality were assessed. The definition of VS was a viral load ≤1000 copies/ml. Time to event analyses were stratified by site, median age and gender. Kaplan-Meier curves were calculated and graphed with log-rank modelling to compare curves., Results: Based on 2741 patient-years of follow-up, retention and mortality did not differ between sites. Among all 1000 participants, 47%, 84% and 91% had achieved VS by 6, 12 and 24 months, respectively, which was observed earlier in the peri-urban site. At both sites, men aged < 32 years had the highest proportion of VF (15.5%), while women aged > 32 years had the lowest, at 7.1% (p = 0.018). Among 55 genotypes, 42 (76.4%) had at one or more resistance mutations, which did not differ by site. K103N (59%) and M184V (52%) were the most common mutations, followed by V106M and K65R (31% each). Overall, death was infrequent (< 4%)., Conclusions: No significant differences in treatment outcomes between peri-urban and rural clinics were observed. In both settings, young men were especially susceptible to clinic attrition and VF. More effective adherence support for this important demographic group is needed to achieve UNAIDS targets., (© 2022 British HIV Association.)

Background: Electronic Health Records (EHRs) can help clinicians to plan, document and deliver care for patients in healthcare services. When used consistently, EHRs can advance patient safety and quality, and reduce clinician's workload. However, usability problems can make it difficult for clinicians to use EHRs effectively, which can negatively impact both healthcare professionals and patients., Objective: To improve usability of EHRs within a mental health service in the UK., Methods: This was a feasibility study conducted with two mental health teams. A mixed-methods approach was employed. Focus group discussions with clinicians identified existing usability problems in EHRs and changes were made to address these problems. Updated EHR assessment forms were evaluated by comparing the following measures pre and post changes: (1) usability testing to monitor time spent completing and duplicating patient information in EHRs, (2) clinician's experience of using EHRs, and (3) proportion of completed EHR assessment forms., Results: Usability testing with clinicians (n = 3) showed that the time taken to complete EHR assessment forms and time spent duplicating patient information decreased. Clinician's experience of completing EHR assessment forms also significantly improved post changes compared to baseline (n = 71; p < 0.005). There was a significant increase in completion of most EHR forms by both teams after EHR usability improvements (all at p < 0.01)., Conclusions: Usability improvements to EHRs can reduce the time taken to complete forms, advance clinician's experience and increase usage of EHRs. It is important to engage healthcare professionals in the usability improvement process of EHRs in mental health services., (© 2022. The Author(s).)

Introduction: Many families now perform specialist medical procedures at home. Families need appropriate training and support to do this. The aim of this study was to evaluate a library of videos, coproduced with parents and healthcare professionals, to support and educate families caring for a child with a gastrostomy., Methods: A mixed-methods online survey evaluating the videos was completed by 43 family carers who care for children with gastrostomies and 33 healthcare professionals (community-based nurses [n = 16], paediatricians [n = 6], dieticians [n = 6], hospital-based nurses [n = 4], paediatric surgeon [n = 1]) from the United Kingdom. Participants watched a sample of videos, rated statements on the videos and reflected on how the videos could be best used in practice., Results: Both family carers and healthcare professionals perceived the video library as a valuable resource for parents and strongly supported the use of videos in practice. All healthcare professionals and 98% (n = 42) of family carers agreed they would recommend the videos to other families. Family carers found the videos empowering and easy to follow and valued the mixture of healthcare professionals and families featured in the videos. Participants gave clear recommendations for how different video topics should fit within the existing patient pathway., Discussion: Families and healthcare professionals perceived the videos to be an extremely useful resource for parents, supporting them practically and emotionally. Similar coproduced educational materials are needed to support families who perform other medical procedures at home., Patient or Public Contribution: Two parent representatives attended the research meetings from conception of the project and were involved in the design, conduct and dissemination of the surveys. The videos themselves were coproduced with several different families., (© 2022 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Background: People who live in aged care homes have high rates of illness and frailty. Providing evidence-based care to this population is vital to ensure the highest possible quality of life., Objective: In this study (CareTrack Aged, CT Aged), we aimed to develop a comprehensive set of clinical indicators for guideline-adherent, appropriate care of commonly managed conditions and processes in aged care., Methods: Indicators were formulated from recommendations found through systematic searches of Australian and international clinical practice guidelines (CPGs). Experts reviewed the indicators using a multiround modified Delphi process to develop a consensus on what constitutes appropriate care., Results: From 139 CPGs, 5609 recommendations were used to draft 630 indicators. Clinical experts (n = 41) reviewed the indicators over two rounds. A final set of 236 indicators resulted, mapped to 16 conditions and processes of care. The conditions and processes were admission assessment; bladder and bowel problems; cognitive impairment; depression; dysphagia and aspiration; end of life/palliative care; hearing and vision; infection; medication; mobility and falls; nutrition and hydration; oral and dental care; pain; restraint use; skin integrity and sleep., Conclusions: The suite of CT Aged clinical indicators can be used for research and assessment of the quality of care in individual facilities and across organizations to guide improvement and to supplement regulation or accreditation of the aged care sector. They are a step forward for Australian and international aged care sectors, helping to improve transparency so that the level of care delivered to aged care consumers can be rigorously monitored and continuously improved., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

Background: Healthcare and other industries have to manage and coordinate a number of different aims and longer-term ambitions. They must maintain quality, manage costs, support and retain the workforce, manage regulatory demands and consider wider societal objectives. These aims are all legitimate, but they are not necessarily aligned, neither in their time frame nor in their nature. Conflicts between aims have a profound influence on the implementation of safety and quality improvement and wider innovation system change. Healthcare leaders understand that these aims may conflict, but the extent and nature of such conflicts have been underestimated., Objective: This paper aims to support medical and nursing leadership and executives in the complex task of managing multiple aims in relation to improvement and innovation., Methods: We drew on our experience and the wider industrial and healthcare literature to find examples of studies and improvement projects with multiple aims and examples of innovation and change in which conflicting aims were apparent. We sought to identify principles that would enable the management of parallel aims and practical strategies that might facilitate implementation., Results: We argue that almost all improvement and innovation in healthcare should address parallel aims, actively seek to articulate these aims and manage potential conflicts between them. We propose four underlying principles to support a more productive approach to the identification and management of parallel aims: embrace multiple aims, consider both short- and long-term aims and ambitions, consider the wider societal context and appreciate that all changes take place within an evolving, dynamic context. In terms of practical actions, we identified five key strategies: (i) identify and monitor the parallel aims and accept that some will conflict; (ii) slow down to accommodate the natural flexibility of the system; (iii) think both the short term and the long term; (iv) expect and endeavour to anticipate some unintended consequences and (v) resist downgrading the project to partial implementation., Conclusions: We have argued that most improvement and innovation, unlike controlled trials, should consider multiple aims. We set out some broad principles and practices to reduce conflict and suggest avenues to manage conflicts and support positive synergies. We suggest that if this is not done, conflicts are much more likely to arise, which will be detrimental to the change process. Articulating the multiple aims and actively seeking to manage them in parallel will promote a more flexible and productive approach to innovation and change., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Despite their considerable prevalence, dynamics of hospital-associated COVID-19 are still not well understood. We assessed the nature and extent of air- and surface-borne SARS-CoV-2 contamination in hospitals to identify hazards of viral dispersal and enable more precise targeting of infection prevention and control. PubMed, ScienceDirect, Web of Science, Medrxiv, and Biorxiv were searched for relevant articles until June 1, 2021. In total, 51 observational cross-sectional studies comprising 6258 samples were included. SARS-CoV-2 RNA was detected in one in six air and surface samples throughout the hospital and up to 7.62 m away from the nearest patients. The highest detection rates and viral concentrations were reported from patient areas. The most frequently and heavily contaminated types of surfaces comprised air outlets and hospital floors. Viable virus was recovered from the air and fomites. Among size-fractionated air samples, only fine aerosols contained viable virus. Aerosol-generating procedures significantly increased (OR air  = 2.56 (1.46-4.51); OR surface  = 1.95 (1.27-2.99)), whereas patient masking significantly decreased air- and surface-borne SARS-CoV-2 contamination (OR air  = 0.41 (0.25-0.70); OR surface  = 0.45 (0.34-0.61)). The nature and extent of hospital contamination indicate that SARS-CoV-2 is likely dispersed conjointly through several transmission routes, including short- and long-range aerosol, droplet, and fomite transmission., (© 2021 The Authors. Indoor Air published by John Wiley & Sons Ltd.)

Objectives: To describe the current work of the Patient Advice and Liaison Service (PALS) and assess the service's potential to resolve concerns and contribute to organisational learning., Design: A qualitative study using semistructured interviews., Setting: Four mental health trusts and four acute trusts in the English National Health Service, a total of eight PALS across different trusts., Participants: Twenty-four participants comprising of PALS staff and clinicians working with PALS teams., Methods: Semistructured interviews were undertaken with participants using video conferencing software. The framework method was used for the analysis of the large qualitative dataset, which is a conventional method of analysis, similar to thematic or qualitative content analysis., Results: PALS teams fulfil their core responsibilities by acting as point of contact for patients, providing information and resolving a variety of recurrent problems, including PALS staff communication, staff attitudes and waiting times. The remit and responsibilities of each PALS has often broadened over time. Barriers to resolving concerns included a lack of awareness of PALS, limited to no policies informing how staff resolve concerns, an emphasis on complaints and the attitude of clinical staff. Senior management had widely differing views on how the PALS should operate and the management of complaints is a much higher priority. Few PALS teams carried out any analysis of the data or shared data within their organisations., Conclusions: PALS teams fulfil their core responsibilities by acting as point of contact for patients, providing information and resolving concerns. PALS staff also act as navigators of services, mediators between families and staff and, occasionally, patient advocates in supporting them to raise concerns. PALS has the potential to reduce complaints, increase patient satisfaction and provide rapid organisational feedback. Achieving this potential will require more awareness and support within organisations together with updated national policy guidance., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Blueberry stunt phytoplasma (BBSP; 'Candidatus Phytoplasma asteris') is an insect-vectored plant pathogen that causes severe yield losses in blueberry (Vaccinium corymbosum), which is the most valuable fruit crop in Canada. Rapid, field-based diagnostic assays are desirable tools for the control of BBSP, as part of an integrated, proactive approach to production management termed biovigilance. We designed and validated a chaperonin-60 (cpn60)-targeted LAMP assay for detection of BBSP, providing a rapid, low cost, field-deployable diagnostic option. Our validation demonstrates that the assay is reproducible, with high analytical specificity and improved sensitivity when compared with 16S rRNA nested PCR. We applied the validated LAMP assay to nearly 2000 blueberry samples from Québec and Nova Scotia over three growing seasons (2016-2018). Our surveys revealed that BBSP is present in most sites across both provinces, though detection of the pathogen in individual plants varied in different tissues across sampling dates and across years, and evidence of spread between plants was limited. To quantify pathogen load in select plants, we designed additional qPCR and ddPCR assays, also based on cpn60. We found that pathogen load fluctuates in individual plants, both within and between growing seasons. Finally, we designed an interactive map to visualize the results of our surveys. These results provide a validated diagnostic assay that can be used as part of a biovigilance strategy for detecting and controlling infections caused by BBSP., (© 2021. The Author(s).)

Existing interventions to reduce self-harm in adolescents admitted to psychiatric wards are usually focused on individual psychological treatments. However, the immediate ward environment in which treatment takes place is an important factor in the success of the treatment and can also influence the likelihood of self-harming behaviours. The aim of the current study was to evaluate changes made to a psychiatric ward environment on incidence of self-harm in adolescents. A quasi-experimental interrupted time series study was conducted on one child and adolescent psychiatric ward. An intervention was developed alongside staff and patients to address the high incidence of self-harm on weekday evenings on the ward. The intervention components involved adding a regular twilight shift (3-11 pm) for nursing staff and introducing a structured evening activity programme on the ward. A segmented regression analysis of an interrupted time series found that the rate of self-harm per 100 bed days was already declining at baseline and continued to decline post-intervention, but the rate of decline was not significant (p = 0.415). However, the proportion of patients self-harming was increasing at baseline and significantly reduced post-intervention (p = 0.001), and this reduction was significantly larger in the evenings (p = 0.004) compared to other times of day (p = 0.09). A tailored intervention targeting the psychiatric ward environment helped to reduce the proportion of adolescents self-harming on the ward. An interrupted time series analysis should be considered for future interventions making changes to health systems over time., (© 2020. The Author(s).)

Objective: The aim of this study was to explore family carers' experiences of training and ongoing support for caring for their child's gastrostomy, and to get their views on how this could be improved., Methods: A mixed-methods online survey with 146 family carers (eg, parents, grandparents) who care for a child with a gastrostomy. Family carers rated their own experience of training and support and made recommendations for how training and support could be improved for future families., Results: The nature and extent of the training family carers reported receiving varied considerably. Many felt that the demonstrations they received in hospital were too brief. Two in five family carers rated their confidence caring for their child's gastrostomy as very low in the first few weeks after surgery. Parents valued ongoing learning and support from other parents and support from community nurses. Videos and simulation practice were rated as useful formats of training, in addition to face-to-face supervised practice with a clinician. Parents liked how real life the example video shown was, and rated nearly all suggested video topics as 'very helpful', especially troubleshooting topics., Conclusions: Our study found substantial variability in family carers' descriptions of the training and support they received to care for their child's gastrostomy. Training often did not meet family carers' needs. We need to invest in better training and support for families and learn from their recommendations. Improvements to training and support for families (eg, through instructional videos) have the potential to improve family carers' confidence and competence, and reduce the risk of problems and complications which cause harm to children and increase demand on National Health Service (NHS) resources., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Incidents of self-harm are common on psychiatric wards. There are a wide variety of therapeutic, social and environmental interventions that have shown some promise in reducing self-harm in in-patient settings, but there is no consensus on the most appropriate means of reducing and managing self-harm during in-patient admissions., Aims: To review interventions used to reduce self-harm and suicide attempts on adolescent and adult psychiatric in-patient wards., Method: A systematic literature search was conducted between 14 March 2019 and 25 January 2021 using PsycINFO and Medline (PROSPERO ID: CRD42019129046). A total of 23 papers were identified for full review., Results: Interventions fell into two categories, therapeutic interventions given to individual patients and organisational interventions aimed at improving patient-staff communication and the overall ward milieu. Dialectical behaviour therapy was the most frequently implemented and effective therapeutic intervention, with seven of eight studies showing some benefit. Three of the six ward-based interventions reduced self-harm. Two studies that used a combined therapeutic and ward-based approach significantly reduced self-harm on the wards. The quality of the studies was highly variable, and some interventions were poorly described. There was no indication of harmful impact of any of the approaches reported in this review., Conclusions: A number of approaches show some promise in reducing self-harm, but the evidence is not strong enough to recommend any particular approach. Current evidence remains weak overall but provides a foundation for a more robust programme of research aimed at providing a more substantial evidence base for this neglected problem on wards.

In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a 'portfolio' approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognised as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organisations need to promote appropriate education and provide coaching, mentorship and support to local leaders., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the technical and relational skills needed to perform these system diagnostic roles. Some safety challenges need leadership from professional associations to provide important resources, peer support and mentorship to sustain safety work., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

A group of commercial orchards from Quebec (Canada) was followed from 1977 to 2019 as part of a project to implement Integrated Pest Management (IPM) practices. Collected data comprised activity of major fruit pests (from monitoring traps), fruit damage at harvest and pesticide applications, from which the annual costs and impacts of protection programs over 42 years were calculated. Activity and fruit damage in commercial orchards were compared to patterns observed in a reference insecticide-free orchard. Some insects (European apple sawfly, codling moth, apple maggot) were more prevalent in the insecticide-free orchard than in commercial orchards, while others were more prevalent in commercial orchards (oblique-banded leafroller) or as prevalent in both orchard types (tarnished plant bug). Annual fruit damage in the insecticide-free orchard was mostly from the apple maggot (up to 98%), the plum curculio (up to 90%) and the codling moth (up to 58%). The average situation was different in commercial orchards, whose damage was mostly from the plum curculio (up to 7.6%), the tarnished plant bug (up to 7.5%) and the oblique-banded leafroller (up to 1.7%). While the number of registered pesticides, the number of applications and the total cost of pesticides gradually increased from 2002 to 2019, the risks incurred, as measured by indicators of environmental and health impacts, followed a downward trend for insecticides and acaricides and varied slightly for fungicides.

Background: Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes., Methods: A cross-sectional questionnaire was administered to surgeons and nurses in August-October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013-15., Results: 218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management., Conclusions: Standardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.

We examined the acceptable risk of self-driving vehicles (SDVs) compared with that of human-driven vehicles (HDVs) and the psychological mechanisms influencing the decision-making regarding acceptable risk through 4 studies conducted in China and South Korea. Participants from both countries required SDVs to be 4-5 times as safe as HDVs (Studies 1 and 4). When an SDV and an HDV were manipulated to exhibit equivalent safety performance, participants' lower trust in the SDV, rather than the higher negative affect evoked by the SDV, accounted for their lower risk acceptance of the SDV (Studies 2 and 3). Both lower trust and higher negative affect accounted for why participants were less willing to ride in the SDV (Study 3). These reproducible findings improve the understanding of public assessment of acceptable risk of SDVs and offer insights for regulating SDVs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Background: Healthcare is amongst the most complex of human systems. Coordinating activities and integrating newer with older ways of treating patients while delivering high-quality, safe care, is challenging. Three landmark reports in 2018 led by (1) the Lancet Global Health Commission, (2) a coalition of the World Health Organization, the Organisation for Economic Co-operation and Development and the World Bank, and (3) the National Academies of Sciences, Engineering and Medicine of the United States propose that health systems need to tackle care quality, create less harm and provide universal health coverage in all nations, but especially low- and middle-income countries. The objective of this study is to review these reports with the aim of advancing the discussion beyond a conceptual diagnosis of quality gaps into identification of practical opportunities for transforming health systems by 2030., Main Body: We analysed the reports via text-mining techniques and content analyses to derive their key themes and concepts. Initiatives to make progress include better measurement, using the capacities of information and communications technologies, taking a systems view of change, supporting systems to be constantly improving, creating learning health systems and undergirding progress with effective research and evaluation. Our analysis suggests that the world needs to move from 2018, the year of reports, to the 2020s, the decade of action. We propose three initiatives to support this move: first, developing a blueprint for change, modifiable to each country's circumstances, to give effect to the reports' recommendations; second, to make tangible steps to reduce inequities within and across health systems, including redistributing resources to areas of greatest need; and third, learning from what goes right to complement current efforts focused on reducing things going wrong. We provide examples of targeted funding which would have major benefits, reduce inequalities, promote universality and be better at learning from successes as well as failures., Conclusion: The reports contain many recommendations, but lack an integrated, implementable, 10-year action plan for the next decade to give effect to their aims to improve care to the most vulnerable, save lives by providing high-quality healthcare and shift to measuring and ensuring better systems- and patient-level outcomes. This article signals what needs to be done to achieve these aims.

Background: Increasing numbers of children with complex health-care needs are cared for at home by their family. The aim of this qualitative study was to explore the challenges experienced by families caring for children who need complex medical care at home., Methods: We conducted a thematic analysis of eleven in-depth interviews with parents who carry out specialist medical procedures (eg, enteral feeding, bowel washouts and tracheostomy care) for their children at home. Participants were purposely selected from an existing sample of interviews with parents whose child had abdominal surgery in the first year of life., Results: We identified three overarching themes: (a) responsibilities of the parent, (b) impact on daily life and (c) the parent journey over time. Parents have substantial responsibilities, including performing medical procedures, managing emergencies (sometimes life-threatening), co-ordinating care and advocating for their child. Their responsibilities have an enormous impact on the family: going out of the home becomes a challenge, there are constant constraints on time, parents are sleep-deprived and there are wider impacts on siblings. The third theme explores the parent journey over time as parents become experts and make sense of the new normal., Discussion: The burden of care on families caring for children with complex medical needs is much greater than is generally understood by either multidisciplinary health-care teams or the general public. Families need to be better prepared and supported for the responsibilities they take on and the burden of care needs to be shared by others., (© 2020 The Authors Health Expectations published by John Wiley & Sons Ltd.)

Background: The Partners at Care Transitions Measure (PACT-M) is a patient-reported questionnaire for evaluation of the quality and safety of care transitions from hospital to home, as experienced by older adults. PACT-M has two components; PACT-M 1 to capture the immediate post discharge period and PACT-M 2 to assess the experience of managing care at home. In this study, we aim to examine the psychometric properties, factor structure, validity and reliability of the PACT-M., Methods: We administered the PACT-M over the phone and by mail, within one week post discharge with 138 participants and one month after discharge with 110 participants. We performed principal components analysis and factors were assessed for internal consistency, reliability and construct validity., Results: Reliability was assessed by calculating Cronbach's alpha for the 9-item PACT-M 1 and 8-item PACT-M 2 and exploratory factor analysis was performed to evaluate dimensionality of the scales. Principal components analysis was chosen using pair-wise deletion. Both PACT-M 1 and PACT-M 2 showed high internal consistency and good internal reliability values and conveyed unidimensional scale characteristics with high reliability scores; above 0.8., Conclusions: The PACT-M has shown evidence to suggest that it is a reliable measure to capture patients' perception of the quality of discharge arrangements and also on patients' ability to manage their care at home one month post discharge. PACT-M 1 is a marker of patient experience of transition and PACT-M 2 of coping at home.

Objectives: Our primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was associations between SSC fidelity and safety culture. We hypothesised that the programme influenced on SSC use and operating theatre personnel's safety culture perceptions., Setting: A longitudinal cross-sectional study was conducted in a large Norwegian tertiary teaching hospital., Participants: We invited 1754 operating theatre personnel to participate in the study, of which 920 responded to the surveys at three time points in 2009, 2010 and 2017., Primary and Secondary Outcome Measures: Primary outcome was the results of the patient safety culture measured by the culturally adapted Norwegian version of the Hospital Survey on Patient Safety Culture. Our previously published results from 2009/2010 were compared with new data collected in 2017. Secondary outcome was correlation between SSC fidelity and safety culture. Fidelity was electronically recorded., Results: Survey response rates were 61% (349/575), 51% (292/569) and 46% (279/610) in 2009, 2010 and 2017, respectively. Eight of the 12 safety culture dimensions significantly improved over time with the largest increase being ' Hospital managers' support to patient safety ' from a mean score of 2.82 at baseline in 2009 to 3.15 in 2017 (mean change: 0.33, 95% CI 0.21 to 0.44). Fidelity in use of the SSC averaged 88% (26 741/30 426) in 2017. Perceptions of safety culture dimensions in 2009 and in 2017 correlated significantly though weakly with fidelity (r=0.07-0.21)., Conclusion: The National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture., Competing Interests: Competing interests: ASH represent the IFNA in the ESA Patient Safety and Quality Committee. NS is the Director of London Safety and Training Solutions Ltd, which provides quality and safety training and advisory services on a consultancy basis to healthcare organisation globally. The other authors report no conflicts of interest. SH had a role as lead of the Scientific Advisory Board appointed by the Norwegian Directorate of Health 2011–2013. IFNA, ESA, London Safety and Training Solutions Ltd., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Constant observation is frequently conducted on inpatient psychiatric units to manage patients at risk of harming themselves or others. Despite its widespread use, there is little evidence of the efficacy of the practice or of its impact on patients and nursing staff. Unnecessary use of this practice can be restrictive and distressing for all involved and can cause considerable strain on healthcare resources. We sought to review interventions aiming to improve the quality and safety of constant observation or to reduce unnecessary use of this restrictive practice on adult inpatient psychiatric wards. A systematic search conducted in December 2018 using PubMed, PsycINFO, CINAHL, EMBASE and Google Scholar identified 24 studies with interventions related to constant observation. Only 16 studies evaluated a total of 13 interventions. The most common intervention components were changes to team, education and training for staff, changes to record keeping and assessment, and involving patients in care. A range of outcome measures were used to evaluate interventions. Over half of the interventions showed some positive impact on constant observation. One study recorded patient feedback. All interventions were targeted towards mental health nurses. Overall, there is no consensus on how best to improve the safety and quality of constant observations or reduce its unnecessary use. Studies vary widely in design, intervention and outcome measures. Existing research does however suggest that teamwork interventions can improve the patient experience of constant observation and safely reduce their degree and frequency. Priorities for future research on constant observations are highlighted., (© 2020 Australian College of Mental Health Nurses Inc.)

Aim: To describe the nature and causes of reported patient safety incidents relating to care in the community for children dependent on long-term ventilation with the further aim of improving safety., Methods: We undertook an analysis of patient safety incident data relating to long-term ventilation in the community using incident reports from England and Wales' National Reporting and Learning System occurring between January 2013 and December 2017. Manual screening by two authors identified 220 incidents which met the inclusion criteria. The free text for each report was descriptively analysed to identify the problems in the delivery of care, the contributory factors and the patient outcome., Results: Common problems in the delivery of care included issues with faulty equipment and the availability of equipment, and concerns around staff competency. There was a clearly stated harm to the child in 89 incidents (40%). Contributory factors included staff shortages, out of hours care, and issues with packaging and instructions for equipment., Conclusions: This study identifies a range of problems relating to long-term ventilation in the community, some of which raise serious safety concerns. The provision of services to support children on long-term ventilation and their families needs to improve. Priorities include training of staff, maintenance and availability of equipment, support for families and coordination of care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Competing interests: We have read and understood BMJ policy on competing interests and have no relevant interests to declare.

Background: Most cancers are diagnosed following contact with primary care. Patients diagnosed with cancer often see their doctor multiple times with potentially relevant symptoms before being referred to see a specialist, suggesting missed opportunities during doctor-patient conversations., Objective: To understand doctor-patient communication around the significance of persistent or new presenting problems and its potential impact on timely cancer diagnosis., Research Design: Qualitative thematic analysis based on video recordings of doctor-patient consultations in primary care and follow-up interviews with patients and doctors. 80 video observations, 20 patient interviews and 7 doctor interviews across 7 general practices in England., Results: We found that timeliness of diagnosis may be adversely affected if doctors and patients do not come to an agreement about the presenting problem's significance. 'Disagreements' may involve misaligned cognitive factors such as differences in medical knowledge between doctor and patient or misaligned emotional factors such as patients' unexpressed fear of diagnostic procedures. Interviews suggested that conversations where the difference in views is either not recognised or stays unresolved may lead to unhelpful patient behaviour after the consultation (eg, non-attendance at specialist appointments), creating potential for diagnostic delay and patient harm., Conclusions: Our findings highlight how doctor-patient consultations can impact timely diagnosis when patients present with persistent or new problems. Misalignments were common and could go unnoticed, leaving gaps for potential to cause patient harm. These findings have implications for timely diagnosis of cancer and other serious disease because they highlight the complexity and fluidity of the consultation and the subsequent impact on the diagnostic process., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Competing interests: None declared.