BMJ Open Quality

Introduction Medicines account for 20% of the National Health Service (NHS) carbon footprint, but it is unclear how consistently they are measured by individual NHS trusts. This study assessed medicine carbon footprint (MCF) practices across NHS trusts in England and whether these changed between 2021 and 2024. Methods Freedom of Information requests were sent to NHS trusts about MCF practices in 2021 and 2024. Responses were analysed to determine the proportion of trusts calculating MCFs, the medicines included and the emission factors used for spend-based calculations. Reported spend-based factors were compared with the median factor for each year to assess the effect of factor choice on MCFs. Results Of 196 trusts included in analysis, 178 (91%) responded for 2021 and 182 (93%) for 2024. Among responding trusts, 30 of 178 calculated MCFs in 2021 compared with 46 of 182 in 2024. Spend-based medicine footprinting increased from 19 trusts in 2021 to 31 in 2024. Ten different factors were used by 15 trusts in 2021 and 13 by 21 trusts in 2024. Reported factors ranged from 31% below to 258% above the median in 2024. Conclusions Medicine carbon footprinting remained uncommon, with only one-quarter of responding NHS trusts calculating a footprint in 2024. Among trusts using spend-based methods, wide variation in emission factors produced substantially different estimated MCFs. Clear national guidance on spend-based methodology could improve consistency in the short term, while greater use of standardised product-level approaches may better support medicine decarbonisation over time.

Background: Patient satisfaction is a key measure of healthcare quality among people experiencing homelessness. Student-run free clinics (SRFCs) provide care to underserved populations, but the role of student involvement in patient satisfaction remains unclear. Methods: We conducted a cross-sectional study of patients receiving care at an SRFC. From February 2024 to February 2025, patients completed post-visit surveys assessing satisfaction that were evaluated using regression analyses. Results: Eighty-eight patients completed surveys, reporting high overall satisfaction (mean 9.26/10). In separate linear regression models adjusted for age, gender, and race, greater perceived benefit of student involvement was associated with higher satisfaction ({beta} = .298, p = .037), whereas perceiving the visit as too long was associated with lower satisfaction ({beta} = -.285, p = .019). Conclusion: Greater perceived benefit of student involvement was associated with higher patient satisfaction, whereas longer perceived visit duration was associated with lower satisfaction. These findings highlight the importance of balancing educational opportunities with efficient workflows in SRFCs.

A. Rationale: Medication-related incidents are an important patient-safety concern, particularly in critical-care and inpatient settings where polypharmacy, clinical complexity, frequent therapeutic modifications, and transitions of care increase the risk of medication errors. Systematic analysis of reported incidents can help identify predominant error patterns, potential contributing factors, and priority areas for quality improvement. The present study was undertaken to characterize medication-related incidents and identify areas requiring targeted patient-safety interventions. B. Research Question What are the predominant patterns and distribution of medication-related incidents across critical-care and inpatient units, what patient-care, process, communication, documentation, and system-level factors potentially contribute to their occurrence, and how can these findings be systematically translated into prioritized, evidence-based quality-improvement interventions to strengthen medication safety and reduce preventable medication-related harm? C. Study Design and Methods A retrospective descriptive observational study was conducted to assess the pattern of medication-related errors identified through medication audits conducted in inpatient and critical-care settings. A total of 74 medication audit records were retrospectively reviewed. Each record was evaluated for the presence and type of medication-related error, including transcription, administration, documentation, and dispensing errors. The identified medication errors were categorized based on the nature of the error documented in the audit records. As individual records could contain more than one type of medication-related error, the error categories were considered non-mutually exclusive. Consequently, the total number of error occurrences could exceed the number of records reviewed. Descriptive statistical analysis was performed using frequency distributions and percentages to determine the relative occurrence of each medication-error category. Pareto analysis was subsequently performed to identify the predominant error categories and establish priorities for quality-improvement interventions. The Pareto analysis demonstrated that transcription and administration errors constituted the major contributors to the observed medication-related errors. The identified error patterns were further evaluated using a process-based patient-safety approach to determine potential failure points within the medication-use process. Poka-Yoke (error-proofing) principles were applied to identify opportunities for preventing or detecting errors at the point of occurrence. Based on the findings, potential interventions included standardization of medication-ordering and transcription processes, mandatory verification of medication details, strengthening of independent verification for high-alert medications, and incorporation of technology-enabled safeguards such as electronic medication administration records and barcode-based medication administration. The findings were used to identify priority areas for targeted quality-improvement interventions aimed at reducing medication-related errors and strengthening the safety and reliability of the medication-use process. D. Results: A total of 91 medication-related error occurrences were identified across the 74 audit records reviewed. Transcription errors constituted the predominant error category (46; 50.5%), followed by administration-related errors (41; 45.1%). Documentation-related and dispensing-related errors accounted for 3 (3.3%) and 1 (1.1%) occurrences, respectively. Pareto analysis demonstrated that transcription and administration-related errors collectively accounted for 87 of the 91 identified occurrences (95.6%), indicating a substantial concentration of medication-related errors within these two categories. The cumulative frequency increased from 50.5% for transcription errors to 95.6% following inclusion of administration-related errors, while the remaining categories contributed only 4.4% of the total error occurrences. Accordingly, transcription and administration-related errors were identified as the principal priority areas for subsequent root cause analysis and quality-improvement interventions. Interpretation: The findings demonstrate that transcription errors (50.5%) and administration-related errors (45.1%) were the predominant medication-related errors, collectively accounting for 87 of the 91 identified error occurrences (95.6%). Documentation-related errors constituted 3.3%, while dispensing-related errors accounted for 1.1% of the observed occurrences. Pareto analysis revealed a marked concentration of medication-related errors within the transcription and administration domains, indicating that these two categories represented the principal areas requiring focused quality-improvement interventions. Subsequent Root Cause Analysis (RCA) and Poka-Yoke-based error-proofing approaches were therefore directed toward identifying and mitigating process vulnerabilities within these high-frequency error domains. Keywords: Medication-related incidents, Medication errors, Patient safety, Critical care, Inpatient care, Medication transcription errors, Medication omission, Medication administration, Root Cause Analysis, Pareto analysis, Poka-Yoke, Error-proofing, Quality improvement, Medication safety, PDSA.

Background: The Greater Manchester Care Record (GMCR) integrates health and social care data for 2.8 million individuals. While it contains maternity information, identifying individual pregnancies, including timing and outcomes, is complex due to variations in healthcare interactions and recording practices. This study develops open-source code to create a pregnancy register within the GMCR using diagnosis- and procedure-based algorithm established in other databases. Methods: 1,448 maternity SNOMED clinical codes identified pregnancy-related primary care records among women aged 14-49 years between March 2012 and August 2023. Codes were grouped by pregnancy outcome, with a hierarchical ruling approach where multiple outcomes appeared within one episode. Pregnancy start dates were derived from hierarchical coded events or imputed using biologically plausible duration based on outcome type. Internal validation compared GMCR register episodes against Hospital Episode Statistics (HES) hospital maternity admissions; external validation compared outcome rates against published UK estimates. Results: The algorithm was developed across 379,832 women, identifying 880,926 pregnancies. Internal validation showed nearly half of register deliveries had a corresponding HES record, with a positive predictive value (PPV) of 48.1%and a median date difference of 17 days (IQR 1-30). External comparison revealed live birth (927.8 vs. 995.6 per 1,000 deliveries) and stillbirth (2.12 vs. 3.9 per 1,000 births) rates close to national estimates but a notable discrepancy for miscarriage (8.00 vs. 15.3 per 100 pregnancies) and termination of pregnancy (5.36 vs. 25.1 per 1,000 women). Demographic alignment was strong for maternal age (31 vs. 29.8 years) and deprivation (IMD10 median: 3 vs. 2.6), though ethnic minority representation was expectedly higher in the GMCR (37.0% vs. 28.7%). Conclusions: This pregnancy register enriches the GMCR for maternal health research, enabling more comprehensive and regionally tailored studies to inform healthcare delivery and policy. This work represents an important first step in developing a scalable, open-source algorithmic tool to support pregnancy research across diverse populations. By making the code openly available, it can be adapted for use in federated data environments, enhancing reproducibility and collaboration.

Background Owing to a growing body of evidence, clinical guidelines now recommend exercise for stroke survivors. However, many stroke survivors are physically inactive and may need more support to engage with exercise in the community. There are between 600-800 exercise referral schemes in the United Kingdom, but engagement from stroke survivors is very low. This study aimed to evaluate the accessibility of exercise referral schemes in England to stroke survivors. Methods A cross-sectional, online survey was conducted throughout England. All 317 local authorities in England were invited to participate. Geospatial mapping was used to visualise the accessibility of exercise referral schemes across England. Data on scheme design and delivery parameters were analysed descriptively. Results Data were collected from 147 local authorities. Exercise referral schemes were offered in 134 local authorities, of which, stroke survivors were able to access 128. However, stroke-specific schemes were available in only 17 local authorities. Significant variations in exercise referral scheme design and delivery were identified across the country. Only two consistencies were found between schemes: the involvement of fitness instructors, and the lack of transport provision. The capacity of exercise referral schemes did not correlate with the general population, stroke population, or stroke prevalence within a local authority. Conclusions Exercise referral schemes are widely available across England, and the majority are open to stroke survivors. However, stroke-specific services are very limited and there is substantial variation in scheme eligibility, capacity, costs, and referral pathways. These inconsistencies, paired with the lack of transport provision, may explain the low uptake of exercise referral schemes within the stroke population.

Background: Patient-facing AI intake chatbots can enter clinical use without regulatory review, so their errors may first surface with actual patients. Objective: To develop and pilot a remote, voice-based standardized patient (SP) method for evaluating an intake chatbot's history-taking, documentation, and patient-centeredness. Methods: Four primary care cases had Easy and Difficult variants. In Phase 1, five SPs completed 40 encounters with internal medicine residents rating portrayal fidelity. In Phase 2, SPs completed 80 encounters with a ChatGPT 4o chatbot, recorded whether critical elements were asked about and addressed satisfactorily, and rated summaries; four debriefing interviews were analyzed. In Phase 3, two blinded clinicians rated transcripts and summaries from 101 encounters (32 resident-led, 69 chatbot-led). Results: Portrayal fidelity averaged 4.52 of 5. The chatbot asked about 59.3% of critical elements in Easy versus 50.2% in Difficult variants (adjusted OR 1.49; 95% CI, 1.15 to 1.93) and addressed 73.3% versus 64.6% (OR 1.47; 1.12 to 1.93); near-ceiling summary quality did not differ. SPs reported missed information and rushed pacing. Reviewer agreement was moderate to substantial for element judgments (AC1 0.49 to 0.70) but poor for totals (ICC 0.10 and 0.21). In exploratory comparisons, residents asked about more elements (adjusted difference 12.5 percentage points; 95% CI, 7.0 to 18.1) and satisfactorily addressed more (9.2 points; 3.8 to 14.6); totals did not differ. Conclusions: SP portrayal was consistent enough for pre-clinical chatbot evaluation, and the method detected lower coverage in harder cases. Documentation ratings alone may miss conversational gaps, which require direct measurement.

Abstract Objectives To conduct a Delphi process to inform an international, consensus definition of manuscript peer review. Design Three-round Delphi consensus study including two surveys and one virtual consensus meeting. Peer review features identified through a prior scoping review were rated on a 5-point Likert scale in Rounds 1 and 2 and voted on using include, exclude, and abstain options in Round 3. Consensus was defined as [≥]80% agreement. Setting International experts representing interest holders affected by manuscript peer review across the fields of biomedical, health, and social sciences, economics, and healthcare-related industries. Participants Round 1 participants were purposively recruited via email from corresponding authors of articles included in the preceding scoping review. Round 2 participants were those who completed Round 1. Round 3 participants were purposely selected to address gaps in representation from earlier rounds, with attention to diversity of perspectives and equity-relevant characteristics informed by PROGRESS-Plus (e.g., geographic location, gender, race/ethnicity, occupation, and socioeconomic context). Participants were required to communicate in English. Main outcome measures Consensus on the terminology, scope, characteristics, functions, processes, and reviewer characteristics that should inform a definition of manuscript peer review. Results Across the three rounds (N=143, 109, and 16 participants, respectively), 44 peer review features across six domains (Characteristics, Function, Motivation, Assessment, Process, and Challenges) and six peer reviewer characteristics met the consensus threshold for inclusion. Consensus was also reached on terminology to describe manuscript peer review and the peer review workflow. Results were synthesized into a final conceptualization of manuscript peer review, consisting of one definition and eight pillars.The consensus definition is: Manuscript peer review is a structured process by which human reviewers assess scholarly manuscripts, with the aim of improving the quality and trustworthiness of published research in line with norms of reciprocity to the research community. The eight pillars characterize manuscript peer review and are as follows: Principled, Constructive, Timely, Transparent, Professional, Quality, Confidential, and Pluralistic. Conclusions This three-round international Delphi established a consensus-based, normative conceptualization of manuscript peer review as a distinct, human-led process to improve the quality and trustworthiness of scholarly research. The resulting definition and eight pillars may provide a shared foundation for research, evaluation, education, and improvement across publishing contexts while allowing operational features to remain adaptable.

Abstract Background Community-based exercise may support physical and cognitive recovery after stroke, but the preferences of stakeholders involved in receiving, supporting and delivering these programmes are poorly understood. This study piloted a discrete choice experiment (DCE) that aimed to evaluate stroke survivors, carers, clinicians, and fitness instructors preferences for community-based exercise programmes for stroke survivors. The pilot aimed to assess the feasibility of conducting and analysing data for a larger-scale study and inform the sample size for a definitive DCE. Methods A DCE design was developed using literature reviews, stakeholder consultations, and evaluations of current services. Six attributes were included in the design: location, price, session frequency, individualisation, carer involvement, and recovery. Sixteen Bayesian D-optimal choice sets were developed, then blocked into two sets of eight to reduce cognitive burden. Main-effects were analysed using a mixed logit model, and stakeholder differences were explored using a conditional logit interaction model. Willingness to pay was also calculated. Results Overall, 161 respondents started the survey and 106 (66%) fully completed it. Stakeholders significantly preferred programmes that were delivered at a leisure centre, lower priced, individualised, had carer-specific sessions and offered greater chances of recovery. The largest willingness-to-pay estimates were {pound}49.41/ month for 80% chance of meaningful recovery vs 20%, and {pound}18.61/ month for leisure centre delivery vs online. Significant preference heterogeneity was identified in the main-effects model. Exploratory stakeholder interactions suggested clinicians were more price sensitive and placed greater importance on recovery and carer-specific sessions than stroke survivors, while fitness instructors placed greater importance on programme location and recovery. Carer interaction estimates were unstable due to the small subgroup sample. Conclusions The pilot supported the feasibility of the DCE design and analytical approach but identified limitations in the recruitment methods and survey completion. Addition of face-to-face recruitment methods are recommended for a larger-scale study. A larger sample size is required to investigate differences in preferences between stakeholder groups.

Background: Multidisciplinary tumor boards (MTBs) are a standard part of cancer care, yet India has no national measure of how many cancer patients are discussed at one. A national survey of hospitals in the National Cancer Registry Programme (NCRP), published in 2026, gives the first structured look at board presence and functioning. Objective: To describe how far hospital-level tumor board presence translates into all-case review, documentation and follow-up, and to define the data needed to measure patient-level coverage. Methods: Secondary analysis of published aggregate data: the ICMR-NCDIR survey of 229 hospitals in the NCRP hospital-based cancer registry (HBCR) network (October 2024), the HBCR 2021 report, national incidence estimates (ICMR-NCDIR 2022; GLOBOCAN 2024) and two published single-center MTB audits. We calculated proportions with Wilson 95% confidence intervals, non-response bounds across all 229 hospitals, and logical bounds for joint conditions. No individual-level data were used. Results: A total of 229 hospitals were invited and 172 responded (75.1%). Among the respondents, 137 (79.7%; 59.8% to 84.7% across all hospitals) reported a functional tumor board. Only 65 respondents (37.8%; 28.4% to 53.3%) reported boards that review all cases, 71 (41.3%) had a follow-up system, 50 (29.1%) used any electronic documentation and 7 (4.1%) always took part in cross-hospital reviews. The share of hospitals with both all-case review and a follow-up system could lie anywhere from 0% to 37.8% of respondents. Boards were reported more often in private (86.6%) than in public hospitals (72.5%). Two single-center audits reported about 800 case discussions (573 new patients) and 1,260 case discussions (about 917 patients) a year, but neither reported new registrations at the same hospital, so coverage could not be calculated. Conclusions: Tumor board presence is common in India, but evidence of all-case review, documentation and follow-up is much thinner, and the share of patients reviewed nationally is unknown. We propose six indicators that hospital-based registries could report to measure coverage directly.

Background: Pregnancy is a uniquely complex ethical and clinical context in which precision medicine approaches, including genomics-driven risk prediction tools, biomarker-based stratification, and data-intensive analytics, are rapidly evolving. There is a need for community consultation on the ethical, social, and practical implications of precision medicine in pregnancy research and healthcare. Aim: The primary aim of this study was to engage healthcare consumers to build consensus on the acceptability of precision medicine approaches in pregnancy research and healthcare. We also sought to identify consumer priorities for future research. Methods: A two-round modified Delphi study was conducted to determine consumer opinions on the use of precision medicine approaches in pregnancy research and healthcare. Seven in-person workshops (round one) were held, with purposeful recruitment to ensure a representative group of healthcare consumers who engage with the healthcare system during pregnancy. These included first-time parents, culturally and linguistically diverse women, Aboriginal and Torres Strait Islander women, and women and their partners who had experienced previous pregnancy complications. Recruitment was conducted through established advocacy networks, and each workshop was facilitated by representatives from each organization. A second-round online survey, based on workshop content, was completed to assess the acceptability of precision medicine and to determine consumer priorities for future precision medicine research on pregnancy health. Results: Precision medicine research and the implementation of new technologies in clinical care were acceptable to participants; however, the need for transparency and trust between participants and researchers regarding the use and storage of genetic material was highlighted, particularly among Aboriginal and culturally and linguistically diverse participants. Outcomes related to survival and perinatal complications (stillbirth, preterm birth, and labor complications) were the highest-rated consumer research priorities, along with maternal mental health and breastfeeding. When asked whether participants would like to see PM available as part of routine pregnancy care for conditions with available treatments, complete consensus (100%) was reached. Conclusion: Healthcare consumers strongly support the use of precision medicine in pregnancy research and its translation into routine clinical care, particularly when effective interventions are available. However, implementation must be underpinned by transparency, trust, culturally appropriate governance, and clear communication about the collection, storage, and use of genetic material. These findings provide a consumer-informed framework for prioritizing future precision medicine research and guiding its responsible translation into pregnancy care.

Background Pediatric neurocritical care (PNCC) has emerged as a distinct field, and many hospitals have moved to establishing dedicated PNCC programs. How practice change is implemented within these programs is not well understood. This study had two objectives. First, we sought to understand the barriers and facilitators of practice change in PNCC from the perspectives of the multiprofessional clinicians who deliver it. Second, we sought to characterize how well the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation determinant framework captures them. Methods We conducted semi-structured interviews with a purposive sample of clinicians involved in PNCC at three U.S. academic medical centers. The interview guide was developed using i-PARIHS to organize barriers and facilitators of practice change across the innovation, recipients, context, and facilitation constructs. We applied framework analysis, combining deductive i-PARIHS, study-specific, and inductively derived categories. Two coders independently indexed the transcripts and reconciled them to consensus, with first-author adjudication. Preliminary site-level findings were validated with participants. Results We interviewed 33 clinicians: 24 physicians, 7 nurses, and 2 advanced practice providers. Most determinants of practice change mapped to existing i-PARIHS constructs, but three were not adequately captured by the framework as currently specified. The most consequential was an interprofessional authority gradient that determined whose preferences prevailed when intensive care, neurology, and neurosurgery disagreed. The other two were clinician autonomy, which served as the lens through which the acceptability of a change was judged, and the affective state clinicians bring to practice change. Receptivity depended more on recipients' values, prior experience, and capacity to absorb change into a demanding workflow. Facilitation was variable, frequently under-resourced, and dependent on credibility across professional groups. We translated these findings into three propositions linked to implementation strategies and outcomes. Conclusions Participants attributed practice change in PNCC more to the recipients of change, the multiprofessional context, and the availability of facilitation than to the strength of evidence for a given practice. i-PARIHS captured most barriers and facilitators well but may be adapted in this setting. Credible, resourced, authority-sensitive facilitation may improve the prospects for sustained practice change as institutions develop PNCC programs.

Introduction Bubble Continuous Positive Airway Pressure (bCPAP) is an effective intervention for managing respiratory distress syndrome among preterm newborns. However, its successful utilization depends on healthcare providers possessing adequate knowledge and practical skills. In Tanzania, competency-based equipment user training has been introduced to strengthen providers' capacity to use neonatal technologies, including bCPAP. Despite these efforts, there is limited qualitative evidence on how this training influences healthcare providers' competence and routine clinical practice. This study explored the role of competency-based equipment user training in enhancing healthcare providers' skills in utilizing bCPAP devices for newborn care in Dar es Salaam, Tanzania. Methods A phenomenological qualitative study was conducted in three regional referral hospitals implementing the NEST360 programme. Purposive sampling was used to recruit doctors and nurses who had completed competency-based equipment user training. Data were collected through in-depth interviews using a semi-structured interview guide and analysed using Braun and Clarke's thematic analysis approach. Findings Six major themes emerged. Participants described competency-based training as a great approach for improving practical skills, confidence, and clinical decision-making regarding patient selection, device operation, monitoring, and weaning. Participants also reported improved equipment maintenance practices, reduced preventable equipment damage, and stronger collaboration with biomedical engineering professional . The training promoted positive changes in provider behaviour, including greater autonomy, internal mentorship of newly recruited staff, and increased accountability for equipment management. Participants further perceived improvements in neonatal care through earlier initiation of bCPAP, fewer unnecessary referrals, and better management of preterm newborns within their facilities. Conclusion Competency-based equipment user training strengthened healthcare providers' competence and confidence in utilizing bCPAP for newborn care while improving equipment management and interdisciplinary collaboration. Integrating competency-based training into routine newborn care programmes may enhance the effective implementation and sustainability of life-saving neonatal technologies in resource-limited settings.

Background: Electronic health records (EHRs) are central to NHS clinical practice, and the value of the data they hold depends on clinicians entering structured data. Structured data entry (SDE) is nonetheless used inconsistently, and most evidence comes from US settings documenting barriers rather than the mechanisms interventions must target. This is, to our knowledge, the first study to apply the Theory of Planned Behaviour (TPB) to SDE, to examine SDE behaviour among UK NHS doctors, and to apply corpus linguistics to clinicians' free-text accounts of EHR use. Methods: A two-part mixed-methods study was conducted at a large NHS teaching hospital in central London using the Epic EHR. Study 1 was a cross-sectional survey of non-consultant grade doctors comprising the System Usability Scale (SUS), a purpose-designed TPB questionnaire, and two open-text questions analysed using corpus linguistics. Study 2 was an Interpretative Phenomenological Analysis (IPA) of semi-structured interviews with six resident doctors. Results: Eighty-three doctors responded; 65 completed the SUS and 49 the TPB questionnaire. Mean SUS score was 62.1 (95% CI 58.3-65.9), below the benchmark of 68 and equivalent to a grade of "D". Structured features were used markedly less often than narrative notes. TPB constructs explained 56% of the variance in intention (F(3,45) = 18.95, p < .001); attitudes (p = .003) and subjective norms (p = .009) predicted intention independently, whereas perceived behavioural control did not (p = .14). Intention predicted self-reported use of problem lists, event-specific templates and standardised documents, but not narrative notes. Corpus analysis identified time pressure and interface friction as dominant barriers. IPA generated four themes: structured documentation as cognitive relief; as fragile collective infrastructure; as a practice clinicians are expected to perform but not enabled to learn; and as a format that can flatten clinical reasoning. Conclusions: Engagement with SDE is driven principally by attitudes and social norms rather than by perceived control, and the barriers clinicians describe arise from the intersection of interface design, training, team norms and institutional expectation. Interventions addressing usability alone are unlikely to succeed: sustained change requires team-level normative reinforcement, specialty-relevant training that explains both how and why, and systems that preserve space for clinical narrative. Keywords: Electronic health records; structured data entry; Theory of Planned Behaviour; System Usability Scale; Interpretative Phenomenological Analysis; corpus linguistics; clinical documentation; data quality; NHS

Awareness of comorbidities in people with dementia is vital context for dementia research and clinical management. Natural Language Processing (NLP) applied to free text in the electronic health record (EHR) may help ascertain comorbidity presence. Our aim was to assess the validity of the MedCAT Comorbidity NLP app in a cohort of people with dementia. We used text from the EHR of South London and Maudsley NHS Mental Health Trust via Clinical Records Interactive Search (CRIS), linked to structured data from local primary care (Lambeth DataNet) and hospital admission data in a cohort of 3,543 people with dementia. We evaluated MedCAT Comorbidity, examining internal validity via manual review of text and external validity by cross-validation against linked primary care and hospital data; and comparison of the predictive value of comorbidity measures for mortality. Internal precision was highest for atrial fibrillation (100%) and lowest for diabetes (78%). Cross-validation with linked data varied substantially across conditions, with precision from 96% to 59% and recall 77% to 4%. The median number of comorbidities identified was two using any single source, or three when combined. MedCAT Comorbidity demonstrated predictive ability for mortality (HR 1.11 per condition), although the model fit was better using comorbidity from hospital admission data. In people with dementia, the MedCAT Comorbidity app showed high precision for most conditions during internal validation. The variability of precision and recall on external validity assessment partly reflects incomplete documentation. Results from the MedCAT comorbidity app can assist researchers in understanding comorbidity of cohorts, particularly when primary care or hospital data is not available. Our findings highlight the need to develop quality assurance protocols that include internal and external validity checks before deploying general data extraction apps for specific clinical subpopulations.

Objective Nurses' specific medication-administration double-check procedures vary widely; while independent double-checks (IDCs) are considered effective and recommended, they are implemented insufficiently in practice. This study aimed to classify these procedures by their component features and determine which features nurses consider desirable and perceive as implemented in clinical practice. Design Cross-sectional web-based vignette study Setting, participants, and methods Nurses working in Japanese hospitals or clinics participated in this study, for which we created 84 scenarios by combining checking procedures' features, including independence between checkers, across the calculation, preparation, and administration stages. For each scenario, participants self-reported the desirability of the procedure and its perceived implementation frequency in their clinical setting. Linear mixed-effects models assessed associations between checking-procedure features and each rating, and McNemar's test assessed discrepancies between desirability and implementation frequency for IDC. Primary outcome Associations between double-check procedures' features and their desirability and implementation frequency, and the alignment between desirability and implementation frequency for IDC Results Of 534 respondents, 265 were analyzed after prespecified attention-check exclusions. Independent checking was positively associated with desirability (b=0.304, 95% CI [0.255, 0.353], p<0.001), perceived implementation frequency for high-risk medications (b=0.140, 95% CI [0.080, 0.200], p<0.001), and non-high-risk medications (b=0.083, 95% CI [0.022, 0.143], p=0.008). Only 22.5% of nurses perceived IDC as the most frequently implemented procedure during the calculation stage. Moreover, 23.4% rated IDC as the most desirable, but did not report it as the most frequently implemented, whereas 8.1% showed the reverse pattern (OR=2.89, 95% CI [1.69, 4.94], p<0.001). Conclusions Although independence, a key feature of IDC, was reflected in nurses' desirability ratings and perceived implementation frequency, IDC was not the most frequently implemented checking procedure, relative to others. Implementing IDC may require not only promoting understanding of its significance but also establishing work protocols and organizational environments that enable independent checking.

Objectives: To assess the feasibility and early performance of an AI-assisted screening workflow that reviews inpatient discharge summaries to identify potential treatment injuries for clinician review and, where appropriate, Accident Compensation Corporation (ACC) treatment injury claim consideration in New Zealand. Design: Single-site, six-month pilot reported as a quality-improvement/service-evaluation activity. A large language model (LLM)-enabled system acted as an index screening test over discharge summaries to generate candidate treatment injury signals for structured clinician adjudication and escalation. Setting: A New Zealand district hospital (Wairarapa). Screening operated on routinely produced inpatient discharge summaries. Participants: All inpatient discharge summaries produced during the pilot period were screened (n = 2,642). The unit of analysis was one discharge summary per inpatient episode. Intervention: An LLM-based screening workflow that outputs structured candidate harm signals with supporting excerpts and a certainty label. Outputs were reviewed by clinicians using a structured adjudication template. Suitable cases could be escalated to senior clinicians and followed through the local ACC treatment injury process. Main outcome measures: Primary outcomes were yield, positive predictive value (PPV) of AI- flagged signals for clinician-adjudicated iatrogenic harm, and the rate of unsupported/hallucinated outputs. Secondary outcomes included overlap with incident reporting and administrative coding, downstream ACC claim outcomes, and clinician review workload. Results: Across 2,642 inpatient discharge summaries screened, the AI-assisted workflow generated 237 candidate signals (yield 9.0%; 95% CI 7.9% to 10.1%). Clinician adjudication classified 102 as confirmed iatrogenic harm, 43 as possible harm requiring additional context, 81 as no harm, and 11 as unsupported/hallucinated outputs. PPV for confirmed harm was 43.0% (95% CI 36.8% to 49.4%). PPV for confirmed-or-possible harm was 61.2% (95% CI 54.9% to 67.1%). Seven ACC treatment injury claims were lodged as a direct result of AI-assisted surfacing; three were accepted, two declined, and two were held/pending at analysis. Organisational ACC data identified 68 treatment injury claims lodged during the same period, of which 17 overlapped with AI-identified cases. Conclusions: AI-assisted screening of discharge summaries can feasibly increase detection of potential treatment injuries for structured clinician review and may support more systematic ACC consideration and safety learning. Safe scaling requires transparent reporting of model and prompt details, robust human adjudication and escalation pathways, and governance controls to mitigate false positives and unsupported outputs. A next-stage evaluation should estimate diagnostic accuracy against a chart-review reference standard and examine implementation outcomes including workload, acceptability, fidelity and sustainability.

Background: Although point-of-care testing is the standard method for inpatient glucose monitoring; it is associated with patient discomfort and late detection of dysglycaemic events. Continuous glucose monitoring (CGM) may improve glycaemic management; however, limited staff education and experience among may hinder its implementation. Aim: To investigate experience, perceptions and training needs on CGM use among inpatient nursing staff across diverse hospital wards. Methods: This is a single-centre, 38-item online survey recruited inpatient nurses in a hospital in the UK. Participants were invited via the e-newsletter and posters; the survey remained open for five months. Results: Nineteen nurses reported positive perceptions of inpatient CGM. Most considered CGM reliable (77.8%) and preferred CGM combined with POCT (66.7%). Views on its impact on workload and patient-room entries were mixed (30% agreed, 30% disagreed). Training needs included sensor placement (92.9%) and alarm management (78.6%). Conclusion: Nurses viewed CGM favourably but highlighted important training needs for inpatient use.

Background Despite being originally developed to support labour monitoring in low-resource and rural settings, the partograph has remained the standard tool for labour management and continues to be used by obstetricians and midwives across diverse settings worldwide. However, inappropriate use and non-use of the partograph persist and have been associated with increased odds of adverse perinatal outcomes, including perinatal death. To address these limitations, the World Health Organization introduced the Labour Care Guide in 2020 as a comprehensive tool to standardise and improve the quality of care during childbirth. Henceforth, some countries such as Rwanda and Uganda have since implemented its use. This study aimed to assess the effect of WHO Labour Care Guide implementation, compared with the traditional partograph, on selected maternal and perinatal outcomes across participating facilities. Methods This was a quasi-experimental implementation study conducted in selected referral hospitals in Zambia, comparing maternal and perinatal outcomes before and after implementation of the WHO Labour Care Guide. Facilities were grouped into implementation and comparison sites. Routine HMIS/DHIS2 data were used to assess selected outcomes across the pre- and post-implementation periods. Descriptive statistics were used to summarise outcome trends, while a difference-in-differences analytical approach was applied using Stata version 18 to compare changes over time between implementation and comparison sites. Results The analysis included 12 hospitals, 192 facility-month observations, 89,122 total births, and 87,004 live births. Overall, the stillbirth rate was 23.8 per 1,000 total births, birth asphyxia rate was 40.1 per 1,000 live births, caesarean section rate was 34.6 per 100 live births, low-birthweight rate was 168.6 per 1,000 live births, and maternal mortality ratio was 313.8 per 100,000 live births. The implementation sites reporting higher birth asphyxia rates (42.7 versus 38.0 per 1,000 live births). Difference-in-differences analysis showed no statistically significant effect of LCG implementation on stillbirths, IRR 1.07 (95% CI: 0.69-1.67, p=0.752); fresh stillbirths, IRR 1.23 (95% CI: 0.74-2.05, p=0.431); birth asphyxia, IRR 0.65 (95% CI: 0.34-1.27, p=0.207); or caesarean section, IRR 1.02 (95% CI: 0.80-1.30, p=0.892). Conclusion Implementation of the WHO Labour Care Guide was not associated with statistically significant changes in stillbirths, fresh stillbirths, birth asphyxia, or caesarean section rates during the study period. Despite the higher birth asphyxia rates in the implementation sites the difference remained statistically not significant. Scale-up of the LCG should be accompanied by sustained training, mentorship, audit and feedback, and strengthening of emergency obstetric and newborn care systems.

Stillbirth remains a major public health concern, particularly in resource-constrained settings. Barriers to timely, high-quality antenatal care may delay the recognition and management of pregnancy complications. We explored the perspectives of women, Village Health Team (VHT) members and healthcare workers on community-delivered approaches to improve pregnancy care, in particular prevention of stillbirth in Uganda. An exploratory qualitative study was conducted at four referral hospitals in Uganda. Data were collected through focus group discussions, in-depth interviews, and key informants interviews with women, Village Health Team members and healthcare workers. Audio-recordings were transcribed verbatim and translated into English where required. Data were analysed thematically using an iteratively developed codebook and NVivo software. In total, 56 participants took part, comprising women (n=27), Village Health Team members (n=11) and frontline healthcare workers (n=18). Participants highlighted the need for the adoption of simple and user-friendly wearable pregnancy monitoring tools for self-monitoring of early warning signs. Health education sessions focused on identifying early warning signs of pregnancy complications highlighted, emphasizing the importance of empowering women with information to seek care early through digital platforms. Limited follow-up support was also a critical concern, with the majority of the women advocating for better emotional and psychological care after a stillbirth, both at a facility and at home. Participants viewed community-delivered antenatal care as an acceptable approach to reducing access barriers. Implementation would require trained personnel, quality-assured tools, clear referral pathways and integration with facility-based care. Structured communication and psychosocial support after stillbirth were also identified as priorities. These findings should inform co-design and prospective evaluation of community-delivered models.

Background: Palliative care is suboptimal in pulmonary fibrosis. Symptom burden is high despite evidence-based interventions, guidelines, and information resources. The application of existing knowledge and methods to optimally manage palliative and end of life care for people with pulmonary fibrosis in the UK has not been realised. Aim: To establish patient views and understanding of how palliative care services and approaches can better meet the needs of people with pulmonary fibrosis. To identify the current barriers and facilitators to receiving palliative care services. Design: Qualitative exploration of patient views via semi-structured interviews and focus groups. Content analysis was conducted. Setting/Participants: The study was conducted from March to August 2024 within an Interstitial Lung Disease Specialist Centre, based in an NHS acute Trust. Results: Two focus groups and four interviews were conducted, involving nine patients. Four overarching themes were identified as to how palliative care can better meet the needs of this group: (1) establishing mechanisms for identifying and addressing palliative care needs; (2) open channels of communication with healthcare professionals; (3) the importance of a palliative care approach within respiratory, community and specialist services; and (4) support for unpaid/family carers. Conclusions: Patients highlighted the importance of person-centred principles and services that adapted to their needs (such as real-time telephone support), rather than services that imposed their own requirements on the patients. Understanding how existing palliative care provision can meet this standard could help improve the palliative and end of life care for people with pulmonary fibrosis.