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Introduction Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts. Methods Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches. Results Forty- six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD. Conclusions The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach. [ABSTRACT FROM AUTHOR]

Background Patients often carry medication lists to mitigate information loss across healthcare settings. We aimed to identify mechanisms by which these lists could be used to support safety, key supporting features, and barriers and facilitators to their use. Methods We used a mixed-methods design comprising two focus groups with patients and carers, 16 semistructured interviews with healthcare professionals, 60 semistructured interviews with people carrying medication lists, a quantitative features analysis of tools available for patients to record their medicines and usability testing of four tools. Findings were triangulated using thematic analysis. Distributed cognition for teamwork models were used as sensitising concepts. Results We identified a wide range of mechanisms through which carrying medication lists can improve medication safety. These included improving the accuracy of medicines reconciliation, allowing identification of potential drug interactions, facilitating communication about medicines, acting as an aide-mémoire to patients during appointments, allowing patients to check their medicines for errors and reminding patients to take and reorder their medicines. Different tools for recording medicines met different needs. Of 103 tools examined, none met the core needs of all users. A key barrier to use was lack of awareness by patients and carers that healthcare information systems can be fragmented, a key facilitator was encouragement from healthcare professionals. Conclusion Our findings suggest that patients and healthcare professionals perceive patient-held medication lists to have a wide variety of benefits. Interventions are needed to raise awareness of the potential role of these lists in enhancing patient safety. Such interventions should empower patients and carers to identify a method that suits them best from a range of options and avoid a 'one size fits all' approach [ABSTRACT FROM AUTHOR]

Background Intentional rounding (IR) is a structured process whereby nurses conduct one to two hourly checks with every patient using a standardised protocol. Objective A realist synthesis of the evidence on IR was undertaken to develop IR programme theories of what works, for whom, in what circumstances and why. Methods A three-stage literature search and a stakeholder consultation event was completed. A variety of sources were searched, including AMED, CINAHL, MEDLINE, PsycINFO, HMIC, Google and Google Scholar, for published and unpublished literature. In line with realist synthesis methodology, each study's 'fltness for purpose' was assessed by considering its relevance and rigour. Results A total of 44 papers met the inclusion criteria. To make the programme theories underpinning IR explicit, we identified eight a priori propositions: (1) when implemented in a comprehensive and consistent way, IR improves healthcare quality and satisfaction, and reduces potential harms; (2) embedding IR into daily routine practice gives nurses 'allocated time to care'; (3) documenting IR checks increases accountability and raises fundamental standards of care; (4) when workload and staffing levels permit, more frequent nurse-patient contact improves relationships and increases awareness of patient comfort and safety needs; (5) increasing time when nurses are in the direct vicinity of patients promotes vigilance, provides reassurance and reduces potential harms; (6) more frequent nurse-patient contact enables nurses to anticipate patient needs and take pre-emptive action; (7) IR documentation facilitates teamwork and communication; and (8) IR empowers patients to ask for what they need to maintain their comfort and well-being. Given the limited evidence base, further research is needed to test and further refine these propositions. Conclusions Despite widespread use of IR, this paper highlights the paradox that there is ambiguity surrounding its purpose and limited evidence of how it works in practice. [ABSTRACT FROM AUTHOR]

Background Concerns with the usability of electronic prescribing (ePrescribing) systems can lead to the development of workarounds by users. Objectives To investigate the types of workarounds users employed, the underlying reasons offered and implications for care provision and patient safety. Methods We collected a large qualitative data set, comprising interviews, observations and project documents, as part of an evaluation of ePrescribing systems in five English hospitals, which we conceptualised as case studies. Data were collected at up to three different time points throughout implementation and adoption. Thematic analysis involving deductive and inductive approaches was facilitated by NVivo 10. Results Our data set consisted of 173 interviews, 24 rounds of observation and 17 documents. Participating hospitals were at various stages of implementing a range of systems with differing functionalities. We identified two types of workarounds: informal and formal. The former were informal practices employed by users not approved by management, which were introduced because of perceived changes to professional roles, issues with system usability and performance and challenges relating to the inaccessibility of hardware. The latter were formalised practices that were promoted by management and occurred when systems posed threats to patient safety and organisational functioning. Both types of workarounds involved using paper and other software systems as intermediaries, which often created new risks relating to a lack of efficient transfer of real-time information between different users. Conclusions Assessing formal and informal workarounds employed by users should be part of routine organisational implementation strategies of major health information new risks and present new opportunities for improvement in system design and integration. [ABSTRACT FROM AUTHOR]

Background Patient decision aids (PDAs) are evidence-based tools designed to help patients make specific and deliberated choices among healthcare options. The International Patient Decision Aid Standards (IPDAS) Collaboration review papers and Cochrane systematic review of PDAs have found significant gaps in the reporting of evaluations of PDAs, including poor or limited reporting of PDA content, development methods and delivery. This study sought to develop and reach consensus on reporting guidelines to improve the quality of publications evaluating PDAs. Methods An international workgroup, consisting of members from IPDAS Collaboration, followed established methods to develop reporting guidelines for PDA evaluation studies. This paper describes the results from three completed phases: (1) planning, (2) drafting and (3) consensus, which included a modified, two-stage, online international Delphi process. The work was conducted over 2 years with bimonthly conference calls and three inperson meetings. The workgroup used input from these phases to produce a final set of recommended items in the form of a checklist. Results The SUNDAE Checklist (Standards for UNiversal reporting of patient Decision Aid Evaluations) includes 26 items recommended for studies reporting evaluations of PDAs. In the two-stage Delphi process, 117/143 (82%) experts from 14 countries completed round 1 and 96/1 17 (82%) completed round 2. Respondents reached a high level of consensus on the importance of the items and indicated strong willingness to use the items when reporting PDA studies. Conclusion The SUNDAE Checklist will help ensure that reports of PDA evaluation studies are understandable, transparent and of high quality. A separate Explanation and Elaboration publication provides additional details to support use of the checklist. [ABSTRACT FROM AUTHOR]

Background Modern medical care requires numerous patient handovers/handoffs. Handover error is recognised as a potential hazard in patient care, and the information error rate has been estimated at 13%. While accurate, reliable handover is essential to high quality care, uncertainty exists as to how intrahospital handover can be improved. This systematic review aims to evaluate the effectiveness of interventions aimed at improving the quality and/ or safety of the intrahospital handover process. Methods We searched for articles on handover improvement interventions in EMBASE, MEDLINE, HMIC and CINAHL between January 2002 and July 2012. We considered studies of: staff knowledge and skills, staff behavioural change, process change or patient outcomes. Results 631 potentially relevant papers were identified from which 29 papers were selected for inclusion (two randomised controlled trials and 27 uncontrolled studies). Most studies addressed shift-change handover and used a median of three outcome measures, but there was no outcome measure common to all. Poor study design and inconsistent reporting methods made it difficult to reach definite conclusions. Information transfer was improved in most relevant studies, while clinical outcome improvement was reported in only two of 10 studies. No difference was noted in the likelihood of success across four types of intervention. Conclusions The current literature does not confirm that any methodology reliably improves the outcomes of clinical handover, although information transfer may be increased. Better study designs and consistency of the terminology used to describe handover and its improvement are urgently required. [ABSTRACT FROM AUTHOR]

Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for the CW initiative, few large-scale changes in rates of low-value care have been reported since the launch of these campaigns. Recent commentaries suggest that the focus of the campaign should be on implementation of evidencebased strategies to effectively reduce low-value care. This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation. The CWDIF consists of five phases: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation of CW recommendations; Phase 2, identification of barriers to implementing CW recommendations and potential interventions to overcome these; Phase 3, rigorous evaluations of CW implementation programmes; Phase 4, spread of effective CW implementation programmes. We provide a worked example of applying the CWDIF to develop and evaluate an implementation programme to reduce unnecessary preoperative testing in healthy patients undergoing low-risk surgeries and to further develop the evidence base to reduce low-value care. [ABSTRACT FROM AUTHOR]

Background Efforts to mitigate unwarranted variation in the quality of care require insight into the 'level' (eg, patient, physician, ward, hospital) at which observed variation exists. This systematic literature review aims to synthesise the results of studies that quantify the extent to which hospitals contribute to variation in quality indicator scores. Methods Embase, Medline, Web of Science, Cochrane and Google Scholar were systematically searched from 2010 to November 2023. We included studies that reported a measure of between-hospital variation in quality indicator scores relative to total variation, typically expressed as a variance partition coefficient (VPC). The results were analysed by disease category and quality indicator type. Results In total, 8373 studies were reviewed, of which 44 met the inclusion criteria. Casemix adjusted variation was studied for multiple disease categories using 144 indicators, divided over 5 types: intermediate clinical outcomes (n=81), final clinical outcomes (n=35), processes (n=10), patient-reported experiences (n=15) and patient-reported outcomes (n=3). In addition to an analysis of between-hospital variation, eight studies also reported physician-level variation (n=54 estimates). In general, variation that could be attributed to hospitals was limited (median VPC=3%, IQR=1%-9%). Between-hospital variation was highest for process indicators (17.4%, 10.8%-33.5%) and lowest for final clinical outcomes (1.4%, 0.6%-4.2%) and patient-reported outcomes (1.0%, 0.9%-1.5%). No clear pattern could be identified in the degree of between-hospital variation by disease category. Furthermore, the studies exhibited limited attention to the reliability of observed differences in indicator scores. Conclusion Hospital-level variation in quality indicator scores is generally small relative to residual variation. However, meaningful variation between hospitals does exist for multiple indicators, especially for care processes which can be directly influenced by hospital policy. Quality improvement strategies are likely to generate more impact if preceded by level-specific and indicator-specific analyses of variation, and when absolute variation is also considered. [ABSTRACT FROM AUTHOR]

Background The positive deviance approach seeks to identify and learn from those who demonstrate exceptional performance. This study sought to explore how multidisciplinary teams deliver exceptionally safe care on medical wards for older people. Methods A qualitative positive deviance study was conducted on four positively deviant and four slightlyabove- average matched comparator wards, which had been identified using routinely collected NHS Safety Thermometer data. In total, 70 multidisciplinary staff participated in eight focus groups to explore staff perceptions about how their teams deliver safe patient care. A thematic analysis was conducted in two stages: first to identify the tools, processes, strategies, and cultural and social contexts that facilitated safety across all wards; and second to generate hypotheses about the characteristics that facilitated 'positively deviant' patient care. Results Based on identifiable qualitative differences between the positively deviant and comparison wards, 14 characteristics were hypothesised to facilitate exceptionally safe care on medical wards for older people. This paper explores five positively deviant characteristics that healthcare professionals considered to be most salient. These included the relational aspects of teamworking, specifically regarding staff knowing one another and working together in truly integrated multidisciplinary teams. The cultural and social context of positively deviant wards was perceived to influence the way in which practical tools (eg, safety briefings and bedside boards) were implemented. Conclusion This study exemplifies that there are no 'silver bullets' to achieving exceptionally safe patient care on medical wards for older people. Healthcare leaders should encourage truly integrated multidisciplinary ward teams where staff know each other well and work as a team. Focusing on these underpinning characteristics may facilitate exceptional performances across a broad range of safety outcomes. [ABSTRACT FROM AUTHOR]

Background Clinicians' satisfaction with encounter decision aids is an important component in facilitating implementation of these tools. We aimed to determine the impact of decision aids supporting shared decision making (SDM) during the clinical encounter on clinician outcomes. Methods We searched nine databases from inception to June 2017. Randomised clinical trials (RCTs) of decision aids used during clinical encounters with an unaided control group were eligible for inclusion. Due to heterogeneity among included studies, we used a narrative evidence synthesis approach. Results Twenty-five papers met inclusion criteria including 22 RCTs and 3 qualitative or mixed-methods studies nested in an RCT, together representing 23 unique trials. These trials evaluated healthcare decisions for cardiovascular prevention and treatment (n=8), treatment of diabetes mellitus (n=3), treatment of osteoporosis (n=2), treatment of depression (n=2), antibiotics to treat acute respiratory infections (n=3), cancer prevention and treatment (n=4) and prenatal diagnosis (n=1). Clinician outcomes were measured in only a minority of studies. Clinicians' satisfaction with decision making was assessed in only 8 (and only 2 of them showed statistically significantly greater satisfaction with the decision aid); only three trials asked if clinicians would recommend the decision aid to colleagues and only five asked if clinicians would use decision aids in the future. Outpatient consultations were not prolonged when a decision aid was used in 9 out of 13 trials. The overall strength of the evidence was low, with the major risk of bias related to lack of blinding of participants and/or outcome assessors. Conclusion Decision aids can improve clinicians' satisfaction with medical decision making and provide helpful information without affecting length of consultation time. Most SDM trials, however, omit outcomes related to clinicians' perspective on the decision making process or the likelihood of using a decision aid in the future. [ABSTRACT FROM AUTHOR]

Audit and feedback (A&F) is a commonly used quality improvement (QI) approach. A Cochrane review indicates that A&F is generally effective and leads to modest improvements in professional practice but with considerable variation in the observed effects. While we have some understanding of factors that enhance the effects of A&F, further research needs to explore when A&F is most likely to be effective and how to optimise it. To do this, we need to move away from two-arm trials of A&F compared with control in favour of head- to-head trials of different ways of providing A&F. This paper describes implementation laboratories involving collaborations between healthcare organisations providing A&F at scale, and researchers, to embed head-to-head trials into routine QI programmes. This can improve effectiveness while producing generalisable knowledge about how to optimise A&F. We also describe an international meta-laboratory that aims to maximise cross-laboratory learning and facilitate coordination of A&F research. [ABSTRACT FROM AUTHOR]

Purpose of study Initiatives to standardise hospital paper-based prescription charts are underway in various countries in an effort to reduce prescribing errors. The aim of this study was to investigate the extent to which prescribing error rates are influenced by prescription chart design and familiarity. Study design In this prospective, randomised, cross-over study, Foundation Year 1 doctors working in five Scottish National Health Service (NHS) Boards participated in study sessions during which they were asked to prescribe lists of medications for five fictional patients using a different design of paper prescription chart for each patient. Each doctor was timed completing each set of prescriptions, and each chart was subsequently assessed against a predefined list of possible errors. A mixed modelling approach using three levels of variables (design of and familiarity with a chart, prescribing speed and individual prescriber) was employed. Results A total of 72 Foundation Year 1 doctors participated in 10 data-collection sessions. Differences in prescription chart design were associated with significant variations in the rates of prescribing error. The charts from NHS Highland and NHS Grampian produced significantly higher error rates than the other three charts. Participants who took longer to complete their prescriptions made significantly fewer errors, but familiarity with a chart did not predict error rate. Conclusions This study has important implications for prescription chart design and prescribing education. The inverse relationship between the time taken to complete a prescribing task and the rate of error emphasises the importance of attention to detail and workload as factors in error causation. Further work is required to identify the characteristics of prescription charts that are protective against errors. [ABSTRACT FROM AUTHOR]

Background Few studies have applied a systems approach to understanding the causes of specific prescribing errors in the context of hospital electronic prescribing (EP). A comprehensive understanding of underlying causes is essential for developing effective interventions to improve prescribing safety. Our objectives were to explore prescribers' perspectives of the causes of errors occurring with EP and to make recommendations to maximise benefits and minimise risks. Methods We studied a large hospital using inpatient EP. From April to June 2016, semistructured interviews were conducted with purposively sampled prescribers involved with a prescribing error. Interviews explored prescribers' perceived causes of the error and views about EP; they were audio-recorded and transcribed verbatim. Data were thematically analysed against a framework based on Reason's accident causation model, with a focus on identifying latent conditions. Results Twenty-five interviews explored causes of 32 errors. Slips and rule-based mistakes were the most common active failures. Error causation was multifactorial; environmental, individual, team, task and technology error-producing conditions were all influenced by EP. There were three broad groups of latent conditions: the EP system's functionality and design; the organisation's decisions around EP implementation and use; and prescribing behaviours in the context of EP. Conclusions Errors were associated with the design of EP itself and its integration within the healthcare environment. Findings suggest that EP vendors should focus on revolutionising interface design and usability issues, bearing in mind the wider healthcare context in which such software is used. Healthcare organisations should draw upon human factors principles when implementing EP. Consideration of work environment, infrastructure, training, prescribing responsibilities and behaviours should be considered to address local issues identified. [ABSTRACT FROM AUTHOR]

Background Health systems worldwide are increasingly holding boards of healthcare organisations accountable for the quality of care that they provide. Previous empirical research has found associations between certain board practices and higher quality patient care; however, little is known about how boards govern for quality improvement (QI). Methods We conducted fieldwork over a 30-month period in 15 healthcare provider organisations in England as part of a wider evaluation of a board-level organisational development intervention. Our data comprised board member interviews (n=65), board meeting observations (60 hours) and documents (30 sets of board meeting papers, 15 board minutes and 15 Quality Accounts). We analysed the data using a framework developed from existing evidence of links between board practices and quality of care. We mapped the variation in how boards enacted governance of QI and constructed a measure of QI governance maturity. We then compared organisations to identify the characteristics of those with mature QI governance. Results We found that boards with higher levels of maturity in relation to governing for QI had the following characteristics: explicitly prioritising QI; balancing short-term (external) priorities with long-term (internal) investment in QI; using data for QI, not just quality assurance; engaging staff and patients in QI; and encouraging a culture of continuous improvement. These characteristics appeared to be particularly enabled and facilitated by board-level clinical leaders. Conclusions This study contributes to a deeper understanding of how boards govern for QI. The identified characteristics of organisations with mature QI governance seemed to be enabled by active clinical leadership. Future research should explore the biographies, identities and work practices of board-level clinical leaders and their role in organisation-wide QI. [ABSTRACT FROM AUTHOR]

Background Despite concerns about the degree of compassion in contemporary healthcare, there is a dearth of evidence for health service managers about how to promote compassionate healthcare. This paper reports on the implementation of the Creating Learning Environments for Compassionate Care (CLECC) intervention by four hospital ward nursing teams. CLECC is a workplace educational intervention focused on developing sustainable leadership and work-team practices designed to support team relational capacity and compassionate care delivery. Objectives To identify and explain the extent to which CLECC was implemented into existing work practices by nursing staff, and to inform conclusions about how such interventions can be optimised to support compassionate care in acute settings. Methods Process evaluation guided by normalisation process theory. Data gathered included staff interviews (n=47), observations (n=7 over 26 hours) and ward manager questionnaires on staffing (n=4). Results Frontline staff were keen to participate in CLECC, were able to implement many of the planned activities and valued the benefits to their well-being and to patient care. Nonetheless, factors outside of the direct influence of the ward teams mediated the impact and sustainability of the intervention. These factors included an organisational culture focused on tasks and targets that constrained opportunities for staff mutual support and learning. Conclusions Relational work in caregiving organisations depends on individual caregiver agency and on whether or not this work is adequately supported by resources, norms and relationships located in the wider system. High cognitive participation in compassionate nursing care interventions such as CLECC by senior nurse managers is likely to result in improved impact and sustainability. [ABSTRACT FROM AUTHOR]

Background Enhanced recovery after surgery (ERAS) protocols are known to potentially improve the management and outcomes of patients undergoing colorectal surgery, with limited evidence of their implementation in hospital networks and in a large population. We aimed to assess the impact of the implementation of an ERAS protocol in colorectal cancer surgery in the entire region of Piemonte, Italy, supported by an audit and feedback (A&F) intervention. Methods A large, stepped wedge, cluster randomised trial enrolled patients scheduled for elective surgery at 29 general surgery units (clusters). At baseline (first 3 months), standard care was continued in all units. Thereafter, four groups of clusters began to adopt the ERAS protocol successively. By the end of the study, each cluster had a period in which standard care was maintained (control) and a period in which the protocol was applied (experimental). ERAS implementation was supported by initial training and A&F initiatives. The primary endpoint was length of stay (LOS) without outliers (>94th percentile), and the secondary endpoints were outliers for LOS, postoperative medical and surgical complications, quality of recovery and compliance with ERAS items. Results Of 2626 randomised patients, 2397 were included in the LOS analysis (1060 in the control period and 1337 in the experimental period). The mean LOS without outliers was 8.5 days during the control period (SD 3.9) and 7.5 (SD 3.5) during the experimental one. The adjusted difference between the two periods was a reduction of 0.58 days (95% CI -1.07, -0.09; p=0.021). The compliance with ERAS items increased from 52.4% to 67.3% (estimated absolute difference +13%; 95% CI 11.4%, 14.7%). No difference in the occurrence of complications was evidenced (OR 1.22; 95% CI 0.89, 1.68). [ABSTRACT FROM AUTHOR]

Objective To identify factors acting as barriers or enablers to the process of healthcare consent for people with intellectual disability and to understand how to make this process equitable and accessible. Data sources Databases: Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL. Additional articles were obtained from an ancestral search and hand- searching three journals. Eligibility criteria Peer- reviewed original research about the consent process for healthcare interventions, published after 1990, involving adult participants with intellectual disability. Synthesis of results Inductive thematic analysis was used to identify factors affecting informed consent. The findings were reviewed by co- researchers with intellectual disability to ensure they reflected lived experiences, and an easy read summary was created. Results Twenty- three studies were included (1999 to 2020), with a mix of qualitative (n=14), quantitative (n=6) and mixed- methods (n=3) studies. Participant numbers ranged from 9 to 604 people (median 21) and included people with intellectual disability, health professionals, carers and support people, and others working with people with intellectual disability. Six themes were identified: (1) health professionals' attitudes and lack of education, (2) inadequate accessible health information, (3) involvement of support people, (4) systemic constraints, (5) person- centred informed consent and (6) effective communication between health professionals and patients. Themes were barriers (themes 1, 2 and 4), enablers (themes 5 and 6) or both (theme 3). Conclusions Multiple reasons contribute to poor consent practices for people with intellectual disability in current health systems. Recommendations include addressing health professionals' attitudes and lack of education in informed consent with clinician training, the coproduction of accessible information resources and further inclusive research into informed consent for people with intellectual disability. PROSPERO registration CRD42021290548. [ABSTRACT FROM AUTHOR]

Background High-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it. Methods This UK- wide study involved interviews and an online survey inviting free- text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system- level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers. Findings Participants included 106 pregnant women and 105 healthcare professionals and managers/ stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person- centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety. Conclusions This study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research. [ABSTRACT FROM AUTHOR]

Clinical tools for use in practice--such as medicine reconciliation charts, diagnosis support tools and track- and- trigger charts--are endemic in healthcare, but relatively little attention is given to how to optimise their design. User- centred design approaches and co- design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co- dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user- centred methods and co- design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think- aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co- design of a prototype track- and- trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed--one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think- aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large- scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co- design a prototype track- and- trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied. [ABSTRACT FROM AUTHOR]

Developing quality indicators (QI) for national purposes (eg, public disclosure, paying-for-performance) highlights the need to find accessible and reliable data sources for collecting standardised data. The most accurate and reliable data source for collecting clinical and organisational information still remains the medical record. Data collection from electronic medical records (EMR) would be far less burdensome than from paper medical records (PMR). However, the development of EMRs is costly and has suffered from low rates of adoption and barriers of usability even in developed countries. Currently, methods for producing national QIs based on the medical record rely on manual extraction from PMRs. We propose and illustrate such a method. These QIs display feasibility, reliability and discriminative power, and can be used to compare hospitals. They have been implemented nationwide in France since 2006. The method used to develop these QIs could be adapted for use in large-scale programmes of hospital regulation in other, including developing, countries. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital. The intervention comprised three elements, targeted within 24 hours of admission: Nterminal pro-B-type natriuretic peptide (NT-proBNP) test, transthoracic Doppler two-dimensional echocardiography and specialist review by cardiology team. The SHIFTEvidence approach to quality improvement was used. During implementation, July 2015--July 2017, 1169 patients received the intervention. An interrupted time series design was used to evaluate impact on patient outcomes, including 15 618 admissions for 8951 patients. Mixed-effects multiple Poisson and log-linear regression models were fitted for count and continuous outcomes, respectively. Effect sizes are slope change ratios preintervention and post-intervention. The intervention was associated with reductions in emergency readmissions between 7 and 90 days (0.98, 95% CI 0.97 to 1.00), although not readmissions between 0 and 7 days post-discharge. Improvements were seen in in-hospital mortality (0.96, 95% CI 0.95 to 0.98), and there was no change in trend for hospital length of stay. Care process changes were also evaluated. Compliance with NT-proBNP testing was already high in 2014/2015 (162 of 163, 99.4%) and decreased slightly, with increased numbers audited, to 2016/2017 (1082 of 1101, 98.2%). Over this period, rates of echocardiography (84.7-98.9%) and specialist input (51.6-90.4%) improved. Care quality and outcomes can be improved for patients with acute heart failure using a care bundle approach. A systematic approach to quality improvement, and robust evaluation design, can be beneficial in supporting successful improvement and learning. [ABSTRACT FROM AUTHOR]

Background Optimising clinical responses to deteriorating patients is an international indicator of acute healthcare quality. Observation charts incorporating track and trigger systems are an initiative to improve early identification and response to clinical deterioration. A suite of track and trigger 'Observation and Response Charts' were designed in Australia and initially tested in simulated environments. This paper reports initial clinical user experiences and views following implementation of these charts in adult general medical-surgical wards. Methods Across eight trial sites, 44 focus groups were conducted with 218 clinical ward staff, mostly nurses, who received training and had used the charts in routine clinical practice for the preceding 2-6 weeks. Transcripts of audio recordings were analysed for emergent themes using an inductive approach. Findings In this exploration of initial user experiences, key emergent themes were: tensions between vital sign 'ranges versus precision' to support decision making; using a standardised 'generalist chart in a range of specialist practice' areas; issues of 'clinical credibility', 'professional autonomy' and 'influences of doctors' when communicating abnormal signs; and 'permission and autonomy' when escalating care according to the protocol. Across themes, participants presented a range of positive, negative or mixed views. Benefits were identified despite charts not always being used up to their optimal design function. Participants reported tensions between chart objectives and clinical practices, revealing mismatches between design characteristics and human staff experiences. Overall, an initial view of 'increased activity/uncertain benefit' was uncovered. Conclusions Findings particularly reinforced the significant influences of organisational work-based cultures, disciplinary boundaries and interdisciplinary communication on implementation of this new practice chart. Optimal use of all chart design characteristics will be possible when these broader cultural issues are addressed. [ABSTRACT FROM AUTHOR]

Background Electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of health services, but the translation of this into reduced harm for patients remains unclear. This review aimed to synthesise primary qualitative research relating to how stakeholders experience the adoption of ePrescribing/ CPOE systems in hospitals, to help better understand why and how healthcare organisations have not yet realised the full potential of such systems and to inform future implementations and research. Methods We systematically searched 10 bibliographic databases and additional sources for citation searching and grey literature, with no restriction on date or publication language. Qualitative studies exploring the perspectives/experiences of stakeholders with the implementation, management, use and/ or optimisation of ePrescribing/CPOE systems in hospitals were included. Quality assessment combined criteria from the Critical Appraisal Skills Programme Qualitative Checklist and the Standards for Reporting Qualitative Research guidelines. Data were synthesised thematically. Results 79 articles were included. Stakeholders' perspectives reflected a mixed set of positive and negative implications of engaging in ePrescribing/ CPOE as part of their work. These were underpinned by further-reaching change processes. Impacts reported were largely practice related rather than at the organisational level. Factors affecting the implementation process and actions undertaken prior to implementation were perceived as important in understanding ePrescribing/CPOE adoption and impact. Conclusions Implementing organisations and teams should consider the breadth and depth of changes that ePrescribing/CPOE adoption can trigger rather than focus on discrete benefits/problems and favour implementation strategies that: consider the preimplementation context, are responsive to (and transparent about) organisational and stakeholder needs and agendas and which can be sustained effectively over time as implementations develop and gradually transition to routine use and system optimisation. [ABSTRACT FROM AUTHOR]

Missing data are frequently encountered in registries that are used to compare performance across hospitals. The most appropriate method for handling missing data when analysing differences in outcomes between hospitals with a generalised linear mixed model is unclear. We aimed to compare methods for handling missing data when comparing hospitals on ordinal and dichotomous outcomes. We performed a simulation study using data from the Multicentre Randomised Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands (MR CLEAN) Registry, a prospective cohort study in 17 hospitals performing endovascular therapy for ischaemic stroke in the Netherlands. The investigated methods for handling missing data, both case-mix adjustment variables and outcomes, were complete case analysis, single imputation, multiple imputation, single imputation with deletion of imputed outcomes and multiple imputation with deletion of imputed outcomes. Data were generated as missing completely at random (MCAR), missing at random and missing not at random (MNAR) in three scenarios: (1) 10% missing data in case-mix and outcome; (2) 40% missing data in case-mix and outcome; and (3) 40% missing data in case-mix and outcome with varying degree of missing data among hospitals. Bias and reliability of the methods were compared on the mean squared error (MSE, a summary measure combining bias and reliability) relative to the hospital effect estimates from the complete reference data set. For both the ordinal outcome (ie, the modified Rankin Scale) and a common dichotomised version thereof, all methods of handling missing data were biased, likely due to shrinkage of the random effects. The MSE of all methods was on average lowest under MCAR and with fewer missing data, and highest with more missing data and under MNAR. The 'multiple imputation, then deletion' method had the lowest MSE for both outcomes under all simulated patterns of missing data. Thus, when estimating hospital effects on ordinal and dichotomous outcomes in the presence of missing data, the least biased and most reliable method to handle these missing data is 'multiple imputation, then deletion'. [ABSTRACT FROM AUTHOR]

Background The introduction of remote triage and assessment early in the pandemic raised questions about patient safety. We sought to capture patients and clinicians' experiences of the management of suspected acute COVID- 19 and generate wider lessons to inform safer care. Setting and sample UK primary healthcare. A subset of relevant data was drawn from five linked in- pandemic qualitative studies. The data set, on a total of 87 participants recruited via social media, patient groups and snowballing, comprised free text excerpts from narrative interviews (10 survivors of acute COVID- 19), online focus groups (20 patients and 30 clinicians), contributions to a Delphi panel (12 clinicians) and fieldnotes from an online workshop (15 patients, clinicians and stakeholders). Methods Data were uploaded onto NVivo. Coding was initially deductive and informed by WHO and Institute of Medicine frameworks of quality and safety. Further inductive analysis refined our theorisation using a wider range of theories--including those of risk, resilience, crisis management and social justice. Results In the early weeks of the pandemic, patient safety was compromised by the driving logic of 'stay home' and 'protect the NHS', in which both patients and clinicians were encouraged to act in a way that helped reduce pressure on an overloaded system facing a novel pathogen with insufficient staff, tools, processes and systems. Furthermore, patients and clinicians observed a shift to a more transactional approach characterised by overuse of algorithms and decision support tools, limited empathy and lack of holistic assessment. Conclusion Lessons from the pandemic suggest three key strategies are needed to prevent avoidable deaths and inequalities in the next crisis: (1) strengthen system resilience (including improved resourcing and staffing; support of new tools and processes; and recognising primary care's role as the 'risk sink' of the healthcare system); (2) develop evidence- based triage and scoring systems; and (3) address social vulnerability. [ABSTRACT FROM AUTHOR]

Objectives To evaluate whether the Acute Frailty Network (AFN) was more effective than usual practice in supporting older people living with frailty to return home from hospital sooner and healthier. Design Staggered difference- in- difference panel event study allowing for differential effects across intervention cohorts. Setting All English National Health Service (NHS) acute hospital sites. Participants All 1 410 427 NHS patients aged 75+ with high frailty risk who had an emergency hospital admission to acute, general or geriatric medicine departments between 1 January 2012 and 31 March 2019. Intervention Membership of the AFN, a quality improvement collaborative designed to support acute hospitals in England deliver evidence- based care for older people with frailty. 66 hospital sites joined the AFN in six sequential cohorts, the first starting in January 2015, the sixth in May 2018. Usual care was delivered in the remaining 248 control sites. Main outcome measures Length of hospital stay, in- hospital mortality, institutionalisation, hospital readmission. Results No significant effects of AFN membership were found for any of the four outcomes nor were there significant effects for any individual cohort. Conclusions To realise its aims, the AFN might need to develop better resourced intervention and implementation strategies. [ABSTRACT FROM AUTHOR]

Background Although efforts are underway to address social determinants of health (SDOH), little is known about physicians' SDOH practices despite evidence that failing to fully elicit and respond to social needs can compromise patient safety and undermine both the quality and effectiveness of treatment. In particular, interventions designed to enhance response to social needs have not been assessed using actual practice behaviour. In this study, we evaluate the degree to which providing primary care physicians with feedback on their SDOH practice behaviours is associated with increased rates of eliciting and responding to housing and social isolation needs. Methods Unannounced standardised patients (USPs), actors trained to consistently portray clinical scenarios, were sent, incognito, to all five primary care teams in an urban, safety-net healthcare system. Scenarios involved common primary care conditions and each included an underlying housing (eg, mould in the apartment, crowding) and social isolation issue and USPs assessed whether the physician fully elicited these needs and if so, whether or not they addressed them. The intervention consisted of providing physicians with audit/feedback reports of their SDOH practices, along with brief written educational material. A prepost comparison group design was used to evaluate the intervention; four teams received the intervention and one team served as a 'proxy' comparison (no intervention). Preintervention (February 2017 to December 2017) rates of screening for and response to the scripted housing and social needs were compared with intervention period (January 2018 to March 2019) rates for both intervention and comparison teams. Results 108 visits were completed preintervention and 183 during the intervention period. Overall, social needs were not elicited half of the time and fully addressed even less frequently. Rates of identifying the housing responding to housing needs increased significantly for intervention teams (15%-41%; p=0.004) but not for the comparison team (21%-29%; p=0.663). Social isolation was identified more frequently postintervention (53%) compared with baseline (39%; p=0.041) among the intervention teams but remained unchanged for the comparison team (39% vs 32%; p=0.601). Full exploration of social isolation remained low for both intervention and comparison teams. Conclusions Results suggest that physicians may not be consistently screening for or responding to social needs but that receiving feedback on those practices, along with brief targeted education, can improve rates of SDOH screening and response. [ABSTRACT FROM AUTHOR]

Hydroxyurea (HU) is an effective but underused disease- modifying therapy for patients with sickle cell anaemia (SCA). EMBRACE SCD, a sickle cell disease treatment demonstration project, aimed to improve access to HU by increasing prescription (Rx) rates by at least 10% from baseline in children with SCA. The Model for Improvement was used as the quality improvement framework. HU Rx was assessed from clinical databases in three paediatric haematology centres. Children aged 9 months-18 years with SCA not on chronic transfusions were eligible for HU treatment. The health belief model was the conceptual framework to discuss with patients and promote HU acceptance. A visual aid showing erythrocytes under the effect of HU and the American Society of Hematology HU brochure were used as educational tools. At least 6 months after offering HU, a Barrier Assessment Questionnaire was given to assess reasons for HU acceptance and refusals. If HU was declined, the providers discussed with family again. We conducted chart audits to And missed opportunities to prescribe HU as one plan-do-study-act cycle. At initial measurement, 50.2% of 524 eligible patients had HU prescribed. During the testing and initial implementation phase, the mean performance after 10 data points was 53%. After 2 years, the mean performance was 59%, achieving an 11% increase in mean performance and a 29% increase from initial to the last measurement (64.8% HU Rx). During a 15-month period, 32.1% (N=168) of the eligible patients who were offered HU completed the barrier questionnaire with 19% (N=32) refusing HU, mostly based on not perceiving enough severity of their children's SCA or fearing side effects. Reviewing patient charts for missed opportunity of offering HU with feedback and evaluating the reasons of declining HU via a questionnaire were key components in increasing HU Rx in our population. [ABSTRACT FROM AUTHOR]

Background Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to emergency medical service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well- being and professional development. Methods A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, Embase, AMED, PsycINFO, HMIC, CINAHL and Web of Science, with searches last updated on 2 August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random effects multilevel meta-analyses. Results The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), postevent debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 (95% CI 0.34, 0.67). Feedback to EMS professionals had large effects in improving documentation (d=0.73 (0.00, 1.45)) and protocol adherence (d=0.68 (0.12, 1.24)), as well as small effects in enhancing cardiac arrest performance (d=0.46 (0.06, 0.86)), clinical decision-making (d=0.47 (0.23, 0.72)), ambulance times (d=0.43 (0.12, 0.74)) and survival rates (d=0.22 (0.1 1, 0.33)). The between-study heterogeneity variance was estimated at σ²=0.32 (95% CI 0.22, 0.50), with an I² value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity. Conclusion This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS. PROSPERO registration number CRD42020162600. [ABSTRACT FROM AUTHOR]

Background Problems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS). Methods Mixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a highlevel summary. Results We found an almost universal desire to provide the best quality of care. We identified many 'bright spots' of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care. Conclusions Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported. [ABSTRACT FROM AUTHOR]

Introduction Medical training does not necessarily prepare graduates for the real world of healthcare in which continual improvement is required. Doctors in postgraduate training (DrPGT) rarely have the opportunity to develop skills to implement changes where they work. Paradoxically they are often best placed to identify safety and quality concerns and can innovate across organisational boundaries. In order to address this, educational programmes require a supportive educational environment and should include experiential learning on a safety and quality project, alongside teaching of quality improvement (QI) knowledge and systems theory. Method Enabling Doctors in Quality Improvement and Patient Safety (EQuIP) has been designed for DrPGT at a London children's hospital. The aim is to prepare trainees for the future of continual improvement to ensure safe and effective services are developed through effective clinical microsystems. This paper describes the rationale and design of EQuIP with evaluation built in the evolving programme. EQuIP supports DrPGTs through a QI project within their department, aligned to the Great Ormond Street NHS Foundation Trust's objectives. This changes the way DrPGTs view healthcare as they become quality champions for their department. A three-level approach to the programme is described. The innovation involves a peer-designed programme while being work-based, delivering organisational strategies. Results Results of the preprogramme and postprogramme evaluations demonstrate an improvement in knowledge, skills and attitudes. Benefits to both the DrPGTs and the organisation are emphasised and key factors to achieve success and barriers identified by the participants. Discussion The design and evaluation of EQuIP may inform similar educational programmes in other organisations. This capacity building is crucial to ensure that future clinical leaders have the skills and motivation to improve the effectiveness of clinical microsystems. [ABSTRACT FROM AUTHOR]

Objective To characterise the safety hazards related to e-prescribing in community pharmacies. Methods The sociotechnical systems framework was used to investigate the e-prescribing technology interface in community pharmacies by taking into consideration the social, technical and environmental work elements of a user's interaction with technology. This study focused specifically on aspects of the social subsystem. Study design and setting The study employed a cross-sectional qualitative design and was conducted in seven community pharmacies in Wisconsin. Direct observations, think aloud protocols and group interviews were conducted with 14 pharmacists and 16 technicians, and audio recorded. Recordings were transcribed and subjected to thematic content analysis guided by the sociotechnical systems' theoretical framework. Results Three major themes that may increase the potential for medication errors with e- prescribing were identified and described. The three themes included: (1) increased cognitive burden on pharmacy staff, such as having to memorise parts of e-prescriptions or having to perform dosage calculations mentally; (2) interruptions during the e-prescription dispensing process; and (3) communication issues with prescribers, patients and among pharmacy staff. Pharmacy staff reported these consequences of e-prescribing increased the likelihood of medication errors. Conclusions This study is the first of its kind to identify patient safety risks related to e-prescribing in community pharmacies using a sociotechnical systems framework. The findings shed light on potential interventions that may enhance patient safety in pharmacies and facilitate improved e-prescribing use. Future studies should confirm patient safety hazards reported and identify ways to use e-prescribing effectively and safely in community pharmacies. [ABSTRACT FROM AUTHOR]

Background A lack of non-technical skills is increasingly recognised as an important underlying cause of adverse events in healthcare. The nature and number of things professionals communicate to each other can be perceived as a product of their use of non-technical skills. This paper describes the development and reliability of an instrument to measure and quantify the use of non-technical skills by direct observations of explicit professional oral communication (EPOC) in the clinical situation. Methods In an iterative process we translated, tested and refined an existing checklist from the aviation industry, called self, human interaction, aircraft, procedures and environment, in the context of healthcare, notably emergency departments (ED) and intensive care units (ICU). The EPOC comprises six dimensions: assertiveness, working with others; task-oriented leadership; people-oriented leadership; situational awareness; planning and anticipation. Each dimension is specified into several concrete items reflecting verbal behaviours. The EPOC was evaluated in four ED and six ICU. Results In the ED and ICU, respectively, 378 and 1144 individual and 51 and 68 contemporaneous observations of individual staff members were conducted. All EPOC dimensions occur frequently, apart from assertiveness, which was hardly observed. Intraclass correlations for the overall EPOC score ranged between 0.85 and 0.91 and for underlying EPOC dimensions between 0.53 and 0.95. Conclusions The EPOC is a new instrument for evaluating the use of non-technical skills in healthcare, which is reliable in two highly different settings. By quantifying professional behaviour the instrument facilitates measurement of behavioural change over time. The results suggest that EPOC can also be translated to other settings. [ABSTRACT FROM AUTHOR]

Introduction This paper describes the evaluation of a 2-day simulation training programme for staff designed to improve teamwork and inpatient care and compassion in an older persons' unit. Objective The programme was designed to improve inpatient care for older people by using mixed modality simulation exercises to enhance teamwork and empathetic and compassionate care. Methods Healthcare professionals took part in: (a) a 1-day human patient simulation course with six scenarios and (b) a 1-day ward-based simulation course involving five 1-h exercises with integrated debriefing. A mixed methods evaluation included observations of the programme, precourse and postcourse confidence rating scales and follow-up interviews with staff at 7-9 weeks post-training. Results Observations showed enjoyment of the course but some anxiety and apprehension about the simulation environment. Staff self-confidence improved after human patient simulation (t=9; df=56; p<0.001) and ward-based exercises (t=9.3; df=76; p<0.001). Thematic analysis of interview data showed learning in teamwork and patient care. Participants thought that simulation had been beneficial for team practices such as calling for help and verbalising concerns and for improved interaction with patients. Areas to address in future include widening participation across multi-disciplinary teams, enhancing post-training support and exploring further which aspects of the programme enhance compassion and care of older persons. [ABSTRACT FROM AUTHOR]

Background The second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient exposure to each system-level intervention and receipt of each patient-level intervention on these results. Methods This study was conducted at 17 North American Hospitals, the study period was 18 months per site, and sites typically adopted interventions after 2-5 months of preintervention data collection. We conducted an on-treatment analysis (ie, an evaluation of outcomes based on patient exposure) of systemlevel interventions, both at the category level and at the individual component level, based on monthly surveys of implementation site leads at each site (response rate 65%). We then conducted a similar analysis of patient-level interventions, as determined by study pharmacist review of documented activities in the medical record. We analysed the association of each intervention on the adjusted number of medication discrepancies per patient in admission and discharge orders, based on a random sample of up to 22 patients per month per site, using mixed-effects Poisson regression with hospital site as a random effect. We then used a generalised linear mixed-effects model (GLMM) decision tree to determine which patient-level interventions explained the most variance in discrepancy rates. Results Among 4947 patients, patient exposure to seven of the eight system-level component categories was associated with modest but significant reductions in discrepancy rates (adjusted rate ratios (ARR) 0.75-0.97), as were 15 of the 17 individual system-level intervention components, including hiring, reallocating and training personnel to take a best possible medication history (BPMH) and training personnel to perform discharge medication reconciliation and patient counselling. Receipt of five of seven patient-level interventions was independently associated with large reductions in discrepancy rates, including receipt of a BPMH in the emergency department (ED) by a trained clinician (ARR 0.40, 95% CI 0.37 to 0.43), admission medication reconciliation by a trained clinician (ARR 0.57, 95% CI 0.50 to 0.64) and discharge medication reconciliation by a trained clinician (ARR 0.64, 95% CI 0.57 to 0.73). In GLMM decision tree analyses, patients who received both a BPMH in the ED and discharge medication reconciliation by a trained clinician experienced the lowest discrepancy rates (0.08 per medication per patient). Conclusion and relevance Patient-level interventions most associated with reductions in discrepancies were receipt of a BPMH of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were associated with modest reduction in discrepancies for the average patient but are likely important to support patient-level interventions and may reach more patients. These findings can be used to help hospitals and health systems prioritise interventions to improve medication safety during care transitions. [ABSTRACT FROM AUTHOR]

Introduction Intrahospital transitions (IHTs) represent movements of patients during hospitalisation. While transitions are often clinically necessary, such as a transfer from the emergency department to an intensive care unit, transitions may disrupt care coordination, such as discharge planning. Family carers often serve as liaisons between the patient and healthcare professionals. However, carers frequently experience exclusion from care planning during IHTs, potentially decreasing their awareness of patients' clinical status, postdischarge needs and carer preparation. The purpose of this study was to explore family carers' perceptions about IHTs, patient and carer ratings of patient discharge readiness and carer self-perception of preparation to engage in at home care. Methods Sequential, explanatory mixed-methods study involving retrospective analysis of hospital inpatients from a parent study (1R01HS026248; PI Wallace) for whom patient and family carer Readiness for Hospital Discharge Scale (RHDS) score frequency of IHTs and patient and caregiver characteristics were available. Maximum variation sampling was used to recruit a subsample of carers with diverse backgrounds and experiences for the participation in semistructured interviews to understand their views of how IHTs influenced preparation for discharge. Results Of discharged patients from July 2020 to April 2021, a total of 268 had completed the RHDS and 23 completed the semistructured interviews. Most patients experienced 0-2 IHTs and reported high levels of discharge readiness. During quantitative analysis, no association was found between IHTs and patients' RHDS scores. However, carers' perceptions of patient discharge readiness were negatively associated with increased IHTs. Moreover, non-spouse carers reported lower RHDS scores than spousal carers. During interviews, carers shared barriers experienced during IHTs and discussed the importance of inclusion during discharge care planning. Conclusions IHTs often represent disruptive events that may influence carers' understanding of patient readiness for discharge to home and, thus, their own preparation for discharge. Further consideration is needed regarding how to support carers during IHT to facilitate high-quality discharge planning. [ABSTRACT FROM AUTHOR]

Background Patients requiring medical emergency team (MET) review have complex clinical needs, and most remain on the ward after review. Current detection instruments cannot identify post- MET patient requirements, meaning patients remain undistinguished, potentially resulting in missed management opportunities. We propose that deteriorating patients will cluster along dimensions of illness severity and that these clusters may be used to strengthen patient risk management practices. Objective To identify and define the number of illness severity clusters and report outcomes among ward patients following MET review. Study design and setting This retrospective cohort study examined the clinical records of 1500 adult ward patients following MET review at an Australian quaternary hospital. Three- step latent profile analysis methods were used to determine clusters using Sequential Organ Failure Assessment (SOFA) and Nursing Activities Score (NAS) as illness severity indicators. Study outcomes were (1) hospital mortality, (2) unplanned intensive care unit (ICU) admission and (3) subsequent MET review. Results Patients were unplanned (73.9%) and medical (57.5%) admissions with at least one comorbidity (51.4%), and complex combinations of acuity (SOFA range 1--17) and dependency (NAS range 22.4%--148.5%). Five clusters are reported. Patients in cluster 1 were equivalent to clinically stable general ward patients. Organ failure and complexity increased with cluster progression--clusters 2 and 3 were equivalent to subspecialty/ higher- dependency wards, and clusters 4 and 5 were equivalent to ICUs. Patients in cluster 5 had the greatest odds for death (OR 26.2, 95% CI 23.3 to 31.3), unplanned ICU admission (OR 3.1, 95% CI 3.0 to 3.1) and subsequent MET review (OR 2.4, 95% CI 2.4 to 2.6). Conclusion The five illness severity clusters may be used to define patients at risk of poorer outcomes who may benefit from enhanced levels of monitoring and targeted care. [ABSTRACT FROM AUTHOR]

Background Efforts to involve patients in patient safety continue to revolve around professionally derived notions of minimising clinical risk, yet evidence suggests that patients hold perspectives on patient safety that are distinct from clinicians and academics. This study aims to understand how hospital inpatients across three different specialties conceptualise patient safety and develop a conceptual model that reflects their perspectives. Methods A qualitative semi- structured interview study was conducted with 24 inpatients across three clinical specialties (medicine for the elderly, elective surgery and maternity) at a large central London teaching hospital. An abbreviated form of constructivist grounded theory was employed to analyse interview transcripts. Constant comparative analysis and memo- writing using the clustering technique were used to develop a model of how patients conceptualise patient safety. Results While some patients described patient safety using terms consistent with clinical/academic definitions, patients predominantly conceptualised patient safety in the context of what made them 'feel safe'. Patients' feelings of safety arose from a range of care experiences involving specific actors: hospital staff, the patient, their friends/family/carers, and the healthcare organisation. Four types of experiences contributed to how patients conceptualise safety: actions observed by patients; actions received by patients; actions performed by patients themselves; and shared actions involving patients and other actors in their care. Conclusions Our findings support the need for a patient safety paradigm that is meaningful to all stakeholders, incorporating what matters to patients to feel safe in hospital. Additional work should explore and test how the proposed conceptual model can be practically applied and implemented to incorporate the patient conceptualisation of patient safety into everyday clinical practice. [ABSTRACT FROM AUTHOR]

Objective English primary care faces significant challenges, including 'persistent high turnover' of general practitioners (GPs) in some partnerships. It is unknown whether there are specific predictors of persistent high turnover and whether it is associated with poorer population health outcomes. Design A retrospective observational study. Methods We linked workforce data on individual GPs to practice- level data from Hospital Episode Statistics and the GP Patient Survey (2007--2019). We classified practices as experiencing persistent high turnover if more than 10% of GPs changed in at least 3 consecutive years. We used multivariable logistic or linear regression models for panel data with random effects to identify practice characteristics that predicted persistent high turnover and associations of practice outcomes (higher emergency hospital use and patient experience of continuity of care, access to care and overall patient satisfaction) with persistent high turnover. Results Each year, 6% of English practices experienced persistent high turnover, with a maximum of 9% (688/7619) in 2014. Larger practices, in more deprived areas and with a higher morbidity burden were more likely to experience persistent high turnover. Persistent high turnover was associated with 1.8 (95% CI 1.5 to 2.1) more emergency hospital attendances per 100 patients, 0.1 (95% CI 0.1 to 0.2) more admissions per 100 patients, 5.2% (95% CI -5.6% to -4.9%) fewer people seeing their preferred doctor, 10.6% (95% CI-11.4% to -9.8%) fewer people reporting obtaining an appointment on the same day and 1.3% (95% CI -1.6% to -1.1%) lower overall satisfaction with the practice. Conclusions Persistent high turnover is independently linked to indicators of poorer service and health outcomes. Although causality needs to be further investigated, strategies and policies may be needed to both reduce high turnover and support practices facing challenges with high GP turnover when it occurs. [ABSTRACT FROM AUTHOR]

Objectives The study aimed to investigate how the 'natural experiment' of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock. Design Hospital-based cohort study. Setting All public hospitals in Denmark. Participants Patients with an unplanned contact from 1 January 2007 until 31 December 2016. Interventions Stepped-wedge reconfiguration of the Danish emergency healthcare system. Main outcome measures We determined the adjusted ORs for in-hospital mortality and HRs for 30-day mortality using logistic and Cox regression analysis adjusted for sex, age, Charlson Comorbidity Index, income, education, mandatory referral and the changes in the out of hours system in the Capital Region. The main outcomes were stratified by the time of arrival. We performed subgroup analyses on selected diagnoses: myocardial infarction, stroke, pneumonia, aortic aneurysm, bowel perforation, hip fracture and major trauma. Results We included 11 367 655 unplanned hospital contacts. The adjusted OR for overall in- hospital mortality after reconfiguration of the emergency healthcare system was 0.998 (95% CI 0.968 to 1.010; p=0.285), and the adjusted OR for 30-day mortality was 1.004 (95% CI 1.000 to 1.008; p=0.045)). Subgroup analyses showed some possible benefits of the reconfiguration such as a reduction in-hospital and 30-day mortality for myocardial infarction, stroke, aortic aneurysm and major trauma. Conclusions The Danish emergency care reconfiguration programme was not associated with an improvement in overall in-hospital mortality trends and was associated with a slight slowing of prior improvements in 30-day mortality trends. [ABSTRACT FROM AUTHOR]

Background Burnout threatens intensive care unit (ICU) professionals' capacity to provide high-quality care. Moral distress is previously considered a root cause of burnout, but there are other risk factors of burnout such as personality, work--life balance and culture. This study aimed to disentangle the associations of ICU professionals' moral distress and other risk factors with the components of burnout--emotional exhaustion, depersonalisation and personal accomplishment--suggesting informed burnout prevention strategies. Methods Cross- sectional survey completed in 2019 of ICU professionals in two Dutch hospitals. The survey included validated measure for burnout (the Dutch Maslach Burnout Inventory), moral distress (Moral Distress Scale), personality (short Big Five Inventory), work--home balance (Survey Work--Home Interaction Nijmegen) and organisational culture (Culture of Care Barometer). Each of the three components of burnout was analysed as a separate outcome, and for each of the components, a separate regression analysis was carried out. Results 251 ICU professionals responded to the survey (response rate: 53.3%). Burnout prevalence was 22.7%. Findings showed that moral distress was associated with emotional exhaustion (β=0.18, 95% CI 0.9 to 0.26) and depersonalisation (β=0.19, 95% CI 0.10 to 0.28) and with increased emotional exhaustion mediated by negative work- to- home spillover (β=0.09, 95% CI 0.04 to 0.13). Support from direct supervisors mitigates the association between moral distress and emotional exhaustion (β=0.16, 95% CI 0.04 to 0.27). Conclusions Understanding moral distress as a root cause of burnout is too simplified. There is an important interplay between moral distress and work--home imbalance. Interventions that support individual coping with moral distress and a work--home imbalance, and the support of direct supervisors, are paramount to prevent burnout in physicians and nurses. [ABSTRACT FROM AUTHOR]

Background Polypharmacy is an important safety concern. Medication reviews are recommended for patients affected by polypharmacy, but little is known about how they are conducted, nor how clinicians make sense of them. We used video-reflexive ethnography (VRE) to: illuminate how reviews are conducted; elicit professional dialogue and concerns about polypharmacy; invite new transferable understandings of polypharmacy and its management. Methods We conducted 422 hours of fieldwork (participant observation), filmed 18 consultations between clinicians and patients receiving 10 or more regular items of medication (so-called 'higher risk' polypharmacy) and played short clips of film footage to 34 participants (general practitioners, nurses, clinical pharmacists, practice managers) in seven audio-recorded reflexive workshops. Our analysis focused on 'moments of potentiation' and traced clinicians' shifting understandings of their practices. Results Participants rarely referenced biomedical aspects of prescribing (eg, drug- drug interactions, 'Numbers Needed to Treat/Harm') focussing instead on polypharmacy as an emotional and relational challenge. Clinicians initially denigrated their medication review work as mundane. Through VRE they reframed their work as complex, identifying polypharmacy as a delicate matter to negotiate. In patients with multimorbidity and polypharmacy it was difficult to disentangle medication review from other aspects of patients' medical care. Such conditions of complexity presented clinicians with competing professional obligations which were difficult to reconcile. Medication review was identified as an ongoing process, rather than a discrete 'one-off' activity. Meaningful progress towards tackling polypharmacy was only possible through small, incremental, carefully supported changes in which both patient and clinician negotiated a sharing of responsibility, best supported by continuity of care. Conclusions Supporting acceptable, feasible and meaningful progress towards addressing problematic polypharmacy may require shifts in how medication reviews are conceptualised. Responsible decision-making under conditions of such complexity and uncertainty depends crucially on the affective or emotional quality of the clinician-patient relationship. [ABSTRACT FROM AUTHOR]

Background Although clinical peer review is a well-established instrument for improving quality of care, clinical effectiveness is unclear. Methods In a pragmatic cluster randomised controlled trial, we randomly assigned 60 German Initiative Qualitätsmedizin member hospitals with the highest mortality rates in ventilated patients in 2016 to intervention and control groups. The primary outcome was hospital mortality rate in patients ventilated fore more than 24 hours. Clinical peer review was conducted in intervention group hospitals only. We assessed the impact of clinical peer review on mortality using a difference-indiffer7ence approach by applying weighted least squares (WLS) regression to changes in age-adjusted and sex-adjusted standardised mortality ratios (SMRs) 1 year before and 1 year after treatment. Recommendations for improvement from clinical peer review and hospital survey data were used for impact and process analysis. Results We analysed 12 058 and 13 016 patients ventilated fore more than 24 hours in the intervention and control hospitals within the 1-year observation period. In-hospital mortality rates and SMRs were 40.6% and 1.23 in intervention group and 41.9% and 1.28 in control group hospitals in the preintervention period, respectively. The groups showed similar hospital (bed size, ownership) and patient (age, sex, mortality, main indications) characteristics. WLS regression did not yield a significant difference between intervention and control groups regarding changes in SMRs (estimate=0.04, 95% CI= -0.05 to 0.13, p=0.38). Mortality remained high in both groups (intervention: 41.8%, control: 42.1%). Impact and process analysis indicated few perceived outcome improvements or implemented process improvements following the introduction of clinical peer review. Conclusions This study did not provide evidence for reductions in mortality in patients ventilated for more than 24 hours due to clinical peer review. A stronger focus on identification of structures and care processes related to mortality is required to improve the effectiveness of clinical peer review. [ABSTRACT FROM AUTHOR]

Background Healthcare leaders look to high-reliability organisations (HROs) for strategies to improve safety, despite questions about how to translate these strategies into practice. Weick and Sutcliffe describe five principles exhibited by HROs. Interventions aiming to foster these principles are common in healthcare; however, there have been few examinations of the perceptions of those who have planned or experienced these efforts. Objective This single-site qualitative study explores how healthcare professionals understand and enact the HRO principles in response to an HRO-inspired hospital-wide safety programme. Methods We interviewed 71 participants representing hospital executives, programme leadership, and staff and physicians from three clinical services. We observed and collected data from unit and hospital-wide quality and safety meetings and activities. We used thematic analysis to code and analyse the data. Results Participants reported enactment of the HRO principles 'preoccupation with failure', 'reluctance to simplify interpretations' and 'sensitivity to operations', and described the programme as adding legitimacy, training, and support. However, the programme was more often targeted at, and taken up by, nurses compared with other groups. Participants were less able to identify interventions that supported the HRO principles 'commitment to resilience' and 'deference to expertise' and reported limited examples of changes in practices related to these principles. Moreover, we identified inconsistent, and even conflicting, understanding of concepts related to the HRO principles, often related to social and professional norms and practices. Finally, an individualised rather than systemic approach hindered collective actions underlying high reliability. Conclusion Our findings demonstrate that the safety programme supported some HRO principles more than others, and was targeted at, and perceived differently across professional groups leading to inconsistent understanding and enactments of the principles across the organisation. Combining HRO-inspired interventions with more targeted attention to each of the HRO principles could produce greater, more consistent high-reliability practices. [ABSTRACT FROM AUTHOR]

Background There is a need to reduce antimicrobial uses in humans. Previous studies have found variations in antibiotic (AB) prescribing between practices in primary care. This study assessed variability of AB prescribing between clinicians. Methods Clinical Practice Research Datalink, which collects electronic health records in primary care, was used to select anonymised clinicians providing 500+ consultations during 2012--2017. Eight measures of AB prescribing were assessed, such as overall and incidental AB prescribing, repeat AB courses and extent of risk- based prescribing. Poisson regression models with random effect for clinicians were fitted. Results 6111 clinicians from 466 general practices were included. Considerable variability between individual clinicians was found for most AB measures. For example, the rate of AB prescribing varied between 77.4 and 350.3 per 1000 consultations; percentage of repeat AB courses within 30 days ranged from 13.1% to 34.3%; predicted patient risk of hospital admission for infection- related complications in those prescribed AB ranged from 0.03% to 0.32% (5th and 95th percentiles). The adjusted relative rate between clinicians in rates of AB prescribing was 5.23. Weak correlation coefficients (<0.5) were found between most AB measures. There was considerable variability in case mix seen by clinicians. The largest potential impact to reduce AB prescribing could be around encouraging risk- based prescribing and addressing repeat issues of ABs. Reduction of repeat AB courses to prescribing habit of median clinician would save 21 813 AB prescriptions per 1000 clinicians per year. Conclusions The wide variation seen in all measures of AB prescribing and weak correlation between them suggests that a single AB measure, such as prescribing rate, is not sufficient to underpin the optimisation of AB prescribing. [ABSTRACT FROM AUTHOR]

Direct observation is valuable for identifying latent threats and elucidating system complexity in clinical environments. This approach facilitates prospective risk assessment and reveals workarounds, near-misses and recurrent safety problems difficult to diagnose retrospectively or via outcome data alone. As observers are an instrument of data collection, developing effective and comprehensive observer training is critical to ensuring the reliability of the data collection and reproducibility of the research. However, methodological rigour for ensuring these data collection properties remains a key challenge in direct observation research in healthcare. Although prior literature has offered key considerations for observational research in healthcare, operationalising these recommendations may pose a challenge and unless guidance is also provided on observer training. In this article, we offer guidelines for training non-clinical observers to conduct direct observations including conducting a training needs analysis, incorporating practice observations and evaluating observers and inter-rater reliability. The operationalisation of these guidelines is described in the context of a 5-year multisite observational study investigating technology integration in the operating room. We also discuss novel tools developed during the course our project to support data collection and examine inter-rater reliability among observers in direct observation studies. [ABSTRACT FROM AUTHOR]

Background Clinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral. Methods We used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014-2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals. Results 48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18-24 vs 55-64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p<0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p<0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi- morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. Of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia. Conclusions Guideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process. [ABSTRACT FROM AUTHOR]