BMJ Open Quality

Background Advice and Guidance (A&G) enables primary care clinicians to seek specialist input, supporting decision making and avoiding unnecessary referrals. The use of A&G has significantly expanded, accelerated by COVID19 and contractual changes. While A&G is intended to streamline elective care, concerns persist regarding workload shift, variable responsiveness, and system usability. Despite growing policy emphasis, little is known about why clinicians choose to use A&G. Aim Explore the current use of A&G within primary care, focusing on decision making processes which underpin PCCs' decision to use A&G. Design and Setting Qualitative study set in English Primary Care Method Twenty semi structured video interviews were conducted with primary care clinicians purposively sampled for maximum variation. Topic guides were developed with PPIE input and refined iteratively. Data were analysed using reflexive thematic analysis within an interpretive description framework, with themes developed collaboratively and refined through discussion with researchers and PPIE contributors. Ethical approval was obtained (REC 333799). Results Four overarching themes encapsulate clinicians' decisions to use A&G: clinical presentation (acuity and complexity), navigating healthcare pathways, previous experiences of A&G, and using A&G to validate clinical decision making. Barriers included delayed responses and uncertainty about inequitable workload distribution. These factors shape how effectively A&G could be integrated into routine practice. Conclusion Primary care clinicians use A&G to support patient care and aid decision-making, but its effectiveness depends on timely, clinically helpful responses. Ensuring responses remain appropriate to primary care remit and capacity will be essential if A&G becomes the main route into elective care.

BackgroundDespite widespread recognition that patient safety learning can transcend national boundaries, no international patient safety learning system (PSLS) currently exists. There is no expert consensus on the purpose, key requirements, or feasibility of such a system. ObjectiveTo gain consensus from an international panel of healthcare experts regarding the key requirements and feasibility of a potential international PSLS, with or without an incident reporting function. MethodsA two-round modified online Delphi study was conducted with 21 international healthcare experts in patient safety and learning systems, representing all six continents. The study was informed by a prior systematic literature review and semi-structured key-informant interviews with safety-critical industry experts. Panellists rated statements on a 9-point Likert-like scale. Consensus was defined a priori as [≥]70% agreement (ratings 7-9) with an interquartile range (IQR) [≤]2.00. A post-hoc threshold of [≥]80% was applied to identify the strongest areas of consensus. ResultsOf 73 experts invited, 21 completed round one (29% response rate) and 15 completed round two (71% retention). Across two rounds, 103 statements were evaluated; consensus was achieved on 85 (83%) at the [≥]80% threshold across all four domains: purposes (15/19 statements); key functions and features (17/22); patient safety incidents and criteria for international concern (19/24 combined); and enablers and challenges (34/38). The panel endorsed a proposed framework for an international PSLS and generated novel consensus-based lists of patient safety incidents and criteria for determining what should be shared internationally. ConclusionsInternational healthcare experts broadly agree on the purposes, key functions, and feasibility of an international PSLS. The consensus-derived framework provides a foundation for future feasibility research and potential pilot implementation. Validation with frontline end-users is an essential next step. KEY MESSAGESO_ST_ABSWhat is already known on this topicC_ST_ABSNational patient safety learning systems vary considerably in design, governance, and the degree to which they generate actionable learning, and no international system currently exists to enable systematic cross-border sharing and learning from patient safety data. What this study addsThis is the first Delphi study to establish international expert consensus on the purposes, key functions and features, and feasibility of an international Patient Safety Learning System (PSLS), producing novel consensus-based lists of patient safety incidents relevant to international sharing and criteria for determining what constitutes a risk of international concern. How this study might affect research, practice or policyThe proposed framework and consensus-derived criteria provide a starting point for feasibility research and potential pilot implementation by organisations such as the World Health Organization (WHO), in alignment with the Global Patient Safety Action Plan 2021-2030. The findings also highlight the structural prerequisites -- including a standardised international taxonomy, governance frameworks, and equitable participation mechanisms -- that must be addressed before implementation can proceed.

PurposeAlthough numerous research studies have demonstrated the positive impact of clinical pharmacy services, these benefits do not translate into sustained practice changes without support from hospital pharmacy leaders. Factors influencing leadership decisions to expand pharmacy services remained unclear. This study aimed to identify barriers to implementing pharmacy practice model changes and gain insights on potential methods of overcoming these barriers from the hospital pharmacy leader perspective. SummaryWe conducted a national, cross-sectional survey of hospital pharmacy leaders using the REDCap platform, distributed via email over three weeks between September to October 2025. The survey included questions about perceptions related to implementation of practice model changes, resources/evidence used to justify clinical positions, barriers to expanding clinical pharmacy services, and demographics of healthcare systems they represented. The survey included Likert-scales and open-ended questions. The primary outcome was types of evidence most compelling to justify clinical pharmacist positions. Secondary outcomes included resources currently in use for decision-making and perceived barriers. The survey highlighted key factors influencing administrative decision-making regarding the expansion of clinical pharmacy services and revealed significant barriers to justifying clinical positions related to knowledge gaps, underscoring the need for further research to develop evidence-based metrics that capture the comprehensive benefits that clinical pharmacists can offer. ConclusionThis survey provided valuable insights into hospital pharmacy leader perspectives on resources and evidence needed to support expanded pharmacy services and justify clinical pharmacist positions. These insights can inform future research by ensuring that metrics that are both clinically and administratively significant are included in outcomes. Key pointsO_LIWhile clinical pharmacy services are known to improve patient care, their benefits do not lead to expanded and/or sustained practice changes without hospital pharmacy leader support. C_LIO_LIThis cross-sectional survey of hospital pharmacy leaders identified perceptions, resources and barriers to justifying clinical pharmacist positions. C_LIO_LIThis study highlights gaps in hospital pharmacy leader perceptions and knowledge, providing a foundation for developing evidence-based tools and targeted strategies to expand clinical pharmacy services, improve quality of care, and support clinician sustainability. C_LI

Introduction and AimsEffective risk management is essential for improving patient safety, yet limited empirical evidence exists on how risk assessment techniques are used in routine healthcare practice. This study examines current risk management practices in healthcare organisations and compares approaches used in the United States (USA) and the United Kingdom (UK). MethodsA survey of practising healthcare risk managers in both countries examined the use of risk assessment techniques and organisational risk management practices, including team composition and perceived organisational resources. A total of 160 risk managers from the USA and 40 from the UK, representing a wide range of clinical and administrative healthcare areas, participated in the study. ResultsRoot Cause Analysis (RCA) was the most frequently used risk assessment technique in the USA, followed by Failure Modes and Effects Analysis (FMEA). In the UK, risk matrices were most commonly used, followed by Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis. Risk managers in both countries preferred prospective risk management; however, organisational practice in the USA was reported to be significantly more retrospective. Approximately half of respondents reported insufficient organisational resources for effective risk management, most commonly limited time and staffing. In addition, only 43% of USA respondents and 47% of UK respondents reported that recommended risk improvement measures were implemented more than half of the time. ConclusionsHealthcare risk management practices differ between the USA and the UK, particularly in the techniques used, organisational support, and the balance between prospective and retrospective approaches. Strengthening institutional support, increasing multidisciplinary participation, and expanding the use of structured prospective techniques may improve the effectiveness and maturity of healthcare risk management. Key Message (BMJ Requirement)O_ST_ABSWhat is already known on this topic?C_ST_ABSEmpirical studies examining how risk management is conducted in healthcare organisations are limited. Most knowledge about healthcare risk management practice in the United States and the United Kingdom is inferred from guidelines or recommended best practices rather than from studies of actual practice. Evidence regarding risk management practice in UK healthcare institutions is particularly scarce. What this study addsThis study provides empirical evidence on the current state of healthcare risk management practice in the USA and the UK. It identifies the risk assessment techniques most commonly used in healthcare organisations and examines how risk management activities are conducted. The findings highlight strengths and limitations in current practice and provide a comparative perspective on risk management approaches across the two healthcare systems. How this study might affect research, practice, or policyThe study identifies several areas where healthcare risk management practice may be strengthened, including organisational support for risk management, multidisciplinary participation in risk assessment, and implementation of risk improvement measures. The findings also provide insight into the adoption of risk assessment techniques within healthcare, informing future research, policy development, and efforts to improve patient safety management practices.

BackgroundMultiple long-term conditions (MLTC) are increasingly common and place significant strain on healthcare systems designed around single-organ conditions, often resulting in fragmented and reactive care for people living with MLTC. There is limited understanding of how health care professionals (HCPs) make decisions for and with individuals with MLTC at the point of hospital presentation. This study examined how HCPs in emergency and acute settings make decisions around pathways and places of care for people with MLTC, exploring the factors that shape clinical judgement, the challenges HCPs navigate in practice and structures that influence clinical decision-making. MethodsWe conducted semi-structured, individual interviews with 40 NHS professionals working in emergency departments (EDs) and acute assessment units across multiple regions, roles, and specialties. Participants included consultant physicians, resident doctors, senior nursing staff and allied health professionals. Interviews focused on how decisions were made around referrals, admissions, and care planning for people with MLTC. Data were analysed thematically using an inductive approach. ResultsFour themes were identified: A journey of uncertainty, Within and beyond limitations, Structures of care and Implementing relational care. Clinical decision-making is shaped by clinical uncertainty, limited resources, care approaches, and interpersonal relationships and communication. Fragmented services and single-disease pathways complicate care, but participants highlighted the value of continuity, communication, and relational approaches. Challenges include resource limitations, rigid pathways and limited community support. Key enablers of clinical decision-making include integrated care, ownership, and early conversations about priorities. ConclusionsClinical decision-making by HCPs in hospitals for patients with MLTC is complex and shaped by systemic misalignment, where clinical realities clash with health system structures. Improving clinical decision-making around referrals, admissions and care planning for people with MLTC will require adapting systems and training to reflect the realities of MLTC. Potentially beneficial adaptations include strengthening relational and multidisciplinary approaches and expanding intermediate care to reduce avoidable admissions.

BackgroundA Hospital Medicine Advanced Practice Provider (HMAPP)-led care model developed in response to the high acuity and increased patient volumes associated with the Covid-19 pandemic. Although anecdotally perceived as a successful model, questions remained if there was adequate pre-planning and formal implementation strategy for stakeholder buy-in. ObjectiveTo elicit HM physicians and APPs perceptions of the HMAPP-led care model implementation and consider necessary steps for optimal future APP care model development and operation. Design, Setting and ParticipantsThis qualitative study used 10 (5 physicians and 5 APPs involved in the care model pre- and post-implementation) individual semi-structured, virtual interviews based on the Consolidated Framework for Implementation Research (CFIR). Deductive and inductive rapid analysis was utilized to analyze the data. ResultsTwo themes emerged as strengths: 1) Experienced APPs delivered the care model, 2) Acceptance of the care model evolved over time. Four themes suggested opportunities for future development: 1) Guidelines should expand from patient distribution to include minimal collaboration and escalation expectations, 2) Culture change was a barrier to model implementation and acceptance, 3) Intentional collaboration between APPs and Physicians is necessary, 4) Investment in standardized onboarding enhances buy-in of the care model. ConclusionThe impact of an APP care model can be elevated if implemented with key principles and strategies. This is critical in an evolving health care landscape where all providers need to collaborate and practice with their full expertise to maximize safe, efficient and quality patient care.

Background Continuous Quality Improvement (CQI) is a core strategy for strengthening health systems, yet documentation and monitoring of CQI activities remain fragmented in many low- and middle-income country (LMIC) settings. In Jamaica, CQI has been institutionalized across priority programs, but it largely relies on paper-based tools and basic digital platforms that limit timely learning and oversight. To address these gaps, Jamaicas Ministry of Health and Wellness (MOHW), in collaboration with the Caribbean Training and Education Centre for Health (C-TECH), adapted a web-based CQI application using a participatory, human-centered design approach. Methods We conducted a formative, convergent mixed-methods evaluation across 24 healthcare facilities to assess early-stage implementation of the CQI app. Guided by the Implementation Outcomes Framework, we examined acceptability, adoption, appropriateness, and feasibility. Quantitative data were collected through a structured survey of healthcare workers (n=43), and qualitative data were gathered through five focus group discussions (n=33) and three key informant interviews with CQI leads. Survey data were summarized descriptively, and qualitative data were analyzed using rapid qualitative analysis. Findings were integrated using joint displays. Results Survey findings indicated moderate to high perceived acceptability and appropriateness of the CQI app, with 70% of participants reporting that it saved time and 67% noting that it aligned with facility goals. However, 19% reported never using it. Qualitative findings highlighted the apps value for improving CQI documentation, visualizing trends, and supporting supervisory oversight. Key barriers to sustained adoption included inconsistent internet connectivity, limited follow-up training, unclear team roles, and challenges integrating app use into routine workflows. Leadership engagement and alignment with existing CQI structures emerged as critical enablers. Conclusion This formative evaluation suggests that a digitally enabled CQI platform can strengthen documentation and oversight of quality improvement activities in resource-constrained health systems when embedded within supportive organizational and infrastructural contexts. Addressing foundational system readiness, including leadership engagement, capacity-building, and workflow integration, will be essential to realizing the CQI apps potential in Jamaica and similar LMIC settings.

BackgroundIn neonatal hospital care where the population with severe illness has a high mortality rate, around 14.9% of drug prescriptions have errors in Low- and Middle- Income Countries (LMICs) settings. However, there is scant research on interventions to improve medication safety to mitigate such errors. ObjectiveOur objective was to explore a theory-informed pharmacist-led Audit and Feedback (A&F) intervention to improve routine prescribing practices with the aim of reducing gentamicin prescribing errors in neonatal care. MethodsWe used interrupted time series analysis modelling changes in prescribing errors for neonates [≤]28 days admitted to newborn units (NBU) in 22 hospitals in Kenya between July 2021 to June 2024 and explored intervention effects in a feedback meeting at the end of the study. The study had three phases, pre-intervention period (July 2021 to June 2022), intervention period (July 2022 to June 2023), and post-intervention period (July 2023 to June 2024). The primary study was a standard single-group interrupted time-series study (ITS) design to evaluate the comparative effectiveness of enhanced A&F in reducing prescribing error trends after its introduction in 16 hospitals. Secondary analysis included comparison to prescribing error outcomes in an additional six hospitals in a contemporaneous control group that received basic A&F reports without pharmacist involvement in the NBU prescribing practices. ResultsBetween July 2021 and June 2024, the 16 hospitals in the primary outcome analysis and the 6 additional hospitals for the secondary outcome analysis had 36,668 and 8,943 neonates with Gentamicin prescriptions at admission retrospectively. From the incidence rate ratios (IRR) of incorrect prescribing at admission, there was no step change (IRR 1.115, 95% CI: 0.920 to 1.352, p-value=0.265) or trend change (IRR 1.014, 95% CI: 0.986 to 1.042, p-value=0.344) due to the enhanced pharmacist-led A&F intervention in the 16 hospitals in the primary study. From the secondary study, change in the trend post-intervention in the 16 primary study hospitals in the primary study relative to the 6 hospitals acting as a contemporaneous control group was positive (IRR 0.933, 95% CI: 0.878 to 0.985, p-value=0.014), despite no step change due to the enhanced A&F intervention. ConclusionWe found no statistically significant effect of the team-based pharmacist-led A&F intervention on reducing gentamicin medication errors in neonatal care. Prescribing errors during intervention and post-intervention periods were increasing across all hospitals in both arms of the study during and post-intervention periods. However, relative to control hospitals sites receiving routine feedback but without pharmacist involvement or pharmacist-led CMEs, the primary study sites had a positive trend in reducing Gentamicin prescription error rates at admission during and post-introduction of the pharmacist-led A&F intervention. Trial registrationPACTR, PACTR202203869312307. Registered 17th March 2022, https://pactr.samrc.ac.za/Search.aspx?TrialID=PACTR202203869312307 Why was this study done?O_LIIn newborn hospital care where the population with severe illness has a high mortality rate, around 14.9% of drug prescriptions have errors in settings such as sub-Saharan Africa (SSA). C_LIO_LIHowever, there is scant research in SSA on actionable audit and feedback interventions over time to reduce the rates of inappropriate and potentially harmful prescribing of antibiotics. C_LIO_LITherefore, we evaluated whether such an intervention is associated with sustained changes when it provides continuous feedback championed by pharmacists. C_LI What did the researchers do and find?O_LIWe evaluated the impact of a pharmacist-led audit-and feedback intervention for in-hospital newborn care across Kenya. C_LIO_LIWe found that the intervention was not associated with sustained reduction in the level or trend in incorrect antibiotic prescribing across practices, until the study was completed (after 12 months). C_LIO_LIDespite the overall increase in prescribing errors during the study period and the 12 months after the study period, a marked difference in inaccurate prescribing trend was also seen between hospital groups where the hospital pharmacist agreed to be involved with the audit and feedback intervention. C_LI What do these findings mean?O_LIThe extent to which actionable audit and feedback interventions reflect the complexity of routine hospital care in SSA determine whether long-term improvements in prescribing practices can be delivered on an ongoing basis. C_LIO_LIMore research is needed to understand why and how to obtain sustained reductions in antibiotic prescribing errors during hospital stay in SSA. C_LI

BackgroundLiving with multiple long-term conditions (MLTC) is becoming increasingly common with far-reaching consequences for individuals and healthcare systems. People with MLTC often face complex care pathways through health systems - especially hospitals, which are largely configured for specialist treatment of single conditions - yet evidence on people with MLTCs lived experience in the hospital setting is limited. This study aimed to understand the hospital care experiences of people living with MLTC who had recently had an inpatient stay. MethodsPeople with MLTC who had experienced an inpatient stay in hospital within the previous six months were recruited via three hospitals in England and via patient networks. Semi-structured one-to-one interviews were conducted with each participant, focussing on their experiences of care from admission to discharge. An inductive thematic analysis was undertaken. ResultsA total of 44 people (mean age 68.4 years, 23 women) who reported living with between 2 and 11 long-term conditions, the majority of whom (96%) reported that their most recent hospital stay was unplanned, participated in the study. Three themes were constructed from the interview data, reflecting perceptions at individual, interpersonal and organisational levels. Participants experiences were shaped by internalised narratives of hospital care, where care was expected to be focussed primarily on single conditions within a resource-constrained environment. Relationally, the degree of alignment between clinician and patient knowledge on conditions was a key contributor to whether hospital care was experienced positively or negatively, and participants perceptions of organisational constraints to holistic care gave insights into their views on system-level barriers shaping the provision of care for MLTC in the hospital setting. ConclusionExperiences of inpatient hospital care for people with MLTC are complex, diverse and shaped by expectations of care in a specialist setting configured to provide care for single conditions. Healthcare professionals should incorporate patients experiential expertise into decision-making processes through consultation with people with lived experience of MLTC. Redesigning hospital services to provide holistic care will require flexibility to respond to the wide spectrum of MLTC experiences.

Background Therapeutic empathy improves patient and practitioner outcomes, yet existing measures are often lengthy, conceptually inconsistent, and cannot be easily compared across respondent groups. Brief, universal measures (usable by patients, practitioners, students, and observers) are lacking. We therefore developed a universal single-item scale and conducted psychometric testing of the patient-reported version. Methods Following best-practice, we used a three-phase approach: (1) item development; (2) pre-testing the scale by obtaining expert panel feedback (n=9) and conducting cognitive interviews with stakeholders (n=35); and (3) scale validation in an international patient sample (n=521) assessing convergent, discriminant, and known-groups validity. Validation involved assessing correlations with the Consultation and Relational Empathy (CARE) measure and clinical neutrality measure, and by assessing differences in scores by patient ethnicity. Results We developed two versions (pictorial and text-based) of each scale. Expert feedback and cognitive interviews confirmed content and face validity. Pictorial and text-based versions showed high convergent validity with the CARE measure (r=0.761 and r=0.838, both p<0.001), and discriminant validity with a clinical neutrality measure (r=0.131 and r=0.139, p=0.003 and p=0.001, respectively). Correlations with the CARE measure remained high (r>0.70) and statistically significant (p<0.001) across patient gender, ethnicity, and practitioner type. Ethnic minority patients rated practitioner empathy lower than White patients (pictorial p=0.057; text-based p=0.033), demonstrating known-groups validity. Patients rated doctors' empathy higher than other healthcare practitioners' (p=0.001 for both pictorial and text-based); there were no significant differences in empathy scores by patient gender. Conclusions We developed the first universal single-item therapeutic empathy measure and demonstrated validity for the patient-reported versions. The scale is brief, accessible, and applicable to clinical practice, education, and research. Further research should validate practitioner-, student-, and observer-reported versions, and assess predictive and cross-cultural validity. This robust tool can support patient-reported routine measurement of therapeutic empathy and contribute to improving patient and practitioner outcomes.

Acute myocardial infarction (AMI) is an increasing cause of morbidity and mortality in Sub-Saharan Africa (SSA) but is often underdiagnosed and undertreated. To address this gap, the Multicomponent Intervention to Improve Myocardial Infarction Care (MIMIC) was developed and implemented in the emergency department (ED) of a regional referral center in northern Tanzania. We conducted in-depth interviews with 20 key stakeholders (physicians, nurses, administrators, and patients) who participated in MIMIC during the first year of implementation. Purposive sampling was used to recruit a broad range of participants. Interviews were guided by a semi-structured interview guide informed by the Theoretical Framework of Acceptability (TFA). Interview transcripts were thematically analyzed by a team of coders using an inductive, grounded theory approach guided by the seven TFA domains. Nineteen major themes emerged across all TFA domains. Overall, participants described MIMIC as highly acceptable, minimally burdensome, and well-aligned with professional and ethical values. Perceived effectiveness was most emphasized, with staff citing improvements in AMI recognition, ECG and troponin testing, and use of evidence-based therapies. All components were highlighted as effective and easily integrated into existing workflows. Patients valued the educational pamphlet for improving knowledge and self-efficacy, though staff expressed concerns about distributing it during acute care, contributing to inconsistent delivery. Champions were viewed as key in promoting adherence and sustaining implementation of the intervention. MIMIC was widely acceptable in all seven TFA domains among ED providers and patients, with perceived effectiveness driving positive attitudes across stakeholder groups. Use of a co-design approach in MIMIC development likely contributed to high intervention acceptability. Patient education strategies may require adaptation to improve fidelity. These findings suggest that continued implementation and future adaptation of MIMIC may be feasible.

ObjectivesTo explore stakeholder perspectives on care coordination barriers and facilitators in regionalized neuro-oncology delivery, using brain tumors as a model for examining complex care pathways serving mixed rural-urban populations. DesignReflexive thematic analysis of semi-structured interviews from stakeholders across the neuro-oncology care pathway was used to identify themes of care system strengths, systemic barriers to effective service delivery and priorities for system improvement. SettingRegionalized Canadian health system serving one of Ontarios largest catchment areas, characterized by predominantly rural populations and substantial geographic distances to tertiary care. ParticipantsThirty-six stakeholders purposively sampled to represent diverse roles across the care pathway, including family caregivers (n=6), healthcare providers from multiple specialties and care settings (n=28) and Indigenous community advisors (n=2). ResultsTwo main themes with subthemes emerged revealing a tension between localized excellence and systemic fragmentation. Theme 1 (Care System Strengths) included three subthemes: responsive palliative care integration, exceptional provider commitment, and effective intra-institutional communication. Theme 2 (Systemic Barriers to Care Continuity) included four subthemes: absent cross-institutional coordination infrastructure, insufficient pathway standardization, inadequate educational infrastructure for patients and providers and limited regional clinical trial access. Coordination mechanisms functioning effectively within the tertiary center consistently failed at interfaces with referring hospitals and community services, with participants describing patients becoming "lost in transitions." ConclusionsFindings reveal how regionalized cancer systems can achieve localized coordination while failing at system integration. The contrast between internal institutional coherence and external fragmentation suggests that effective care delivery requires deliberately extending coordination mechanisms across organizational boundaries through standardized pathways, shared information systems and defined cross-site accountability structures. Brain tumors, requiring rapid multidisciplinary coordination, expose these interface failures with clarity, offering transferable insights for improving integrated cancer care in regionalized health systems serving geographically dispersed populations. ARTICLE SUMMARYO_ST_ABSStrengths and limitations of this studyC_ST_ABSO_LIPurposive sampling captured diverse stakeholder perspectives across the entire care continuum, from tertiary providers to community services and family caregivers C_LIO_LIReflexive thematic analysis with independent coding by three researchers enhanced interpretive rigor and depth C_LIO_LIBrain tumors function as a model condition for examining care coordination due to their rapid progression and sensitivity to variability in care C_LIO_LISingle health system design limits direct generalizability but enables in-depth examination of coordination mechanisms in a regionalized context C_LIO_LIGeographic and organizational characteristics common to Canadian regionalized systems support transferability of findings C_LIO_LIIndigenous patient perspectives were represented through community advisors; direct patient voices from Indigenous communities would strengthen future work C_LI

BackgroundBehavioral telemetry--the analysis of clinical actions NOT taken--may identify care process failures associated with adverse outcomes. While missed nursing care predicts outcomes in survey-based studies, objective EHR-derived measures are lacking. We hypothesized that missing routine cognitive assessment in ICU patients with low acute physiologic derangement would predict mortality independent of illness severity. MethodsRetrospective cohort study using MIMIC-IV (2008-2022, Beth Israel Deaconess Medical Center) with external assessment of documentation practices in eICU (208 US hospitals). We identified ICU admissions with SOFA 0-2 (low acute physiologic derangement), excluding neurological ICUs. Orientation documentation was classified within 24 hours. Primary outcome was in-hospital mortality. Multivariable logistic regression adjusted for age, sex, SOFA, and Charlson Index. ResultsAmong 46,004 ICU patients with SOFA 0-2, 4,737 (10.3%) had no orientation documentation within 24 hours. These patients had 24.68% mortality versus 7.57% early-assessed and 4.56% late-assessed. After adjustment, missing orientation was associated with 4.29-fold higher odds of death (95% CI 3.95-4.65; E-value 8.0). In SOFA=0 patients (N=23,670), the signal strengthened (OR 5.65, 95% CI 5.03-6.35; E-value 10.8). Late-assessed patients had the LOWEST mortality (OR 0.65), arguing against reverse causation. Patients without orientation had 22% MORE chart events (1,600 vs 1,309), arguing against neglect. External assessment revealed that among 166 eICU hospitals with [&ge;]100 eligible patients, only 5% documented orientation routinely--92% lack the infrastructure to detect this signal. ConclusionsIn ICU patients with low acute physiologic derangement, absence of orientation assessment is associated with 4-6 fold increased mortality. This association may identify care process failures not captured by severity scores, though prospective studies are needed to establish causality. What is Already Known on This TopicMissed nursing care--care omissions--predicts patient mortality in survey-based studies. Nurse staffing ratios are associated with mortality, but the mechanism is poorly understood. No objective, EHR-derived measure exists to detect care process omissions in real time. What This Study AddsFirst EHR-based operationalization of the missed nursing care construct, enabling objective, real-time detection. Missing orientation assessment associated with 4-6 fold increased mortality (OR 4.29 in SOFA 0-2; OR 5.65 in SOFA=0). Signal strengthens in SOFA=0 patients (E-value 10.8), suggesting finding is not driven by acute illness severity. Argues against reverse causation: late assessment has BETTER outcomes than early or no assessment. Argues against neglect: patients without assessment had MORE documentation, not less. Argues against immortal time bias: Never Documented patients had LONGER ICU stays (7.58 vs 3.09 days). Quantifies association: 10.3% of patients account for 27.2% of deaths. Reveals systemic gap: 92% of US ICUs lack the documentation infrastructure to detect this signal. Key PointsO_ST_ABSQuestionC_ST_ABSDoes absence of routine orientation assessment predict mortality in ICU patients with low acute physiologic derangement (SOFA 0-2), independent of illness severity? FindingsIn this cohort study of 46,004 ICU patients with SOFA 0-2, those without orientation documentation within 24 hours had 4.29-fold higher adjusted odds of death (95% CI 3.95-4.65). In SOFA=0 patients, the signal strengthened to OR 5.65 (E-value 10.8). Patients assessed late (6-24h) had the LOWEST mortality (OR 0.65), arguing against reverse causation. Among 166 eICU hospitals, only 5% document orientation routinely-- 92% lack the infrastructure to detect this signal. MeaningMissing routine cognitive assessment may identify care process failures associated with increased mortality. The finding that 92% of US ICUs lack the documentation infrastructure to detect this signal reveals a systemic gap in care process monitoring.

An understated disruption to health services brought about by the Covid-19 pandemic was the increase in deaths occurring outside a hospital. Since quality of end-of-life care is typically monitored through place of death and hospital activity, a new approach focused on care in community settings is needed. In this study, we aimed to test whether patient-centric measures of quality at the end of life can be derived from primary care electronic records. With the approval of NHS England, analysis was undertaken in OpenSAFELY-TPP using electronic health care records of over 970,000 patients who died between March 2019 and August 2023, covering periods before, during and after the pandemic. We developed two new measures of end-of-life care quality--specialist palliative care team contacts and advance care planning, and tracked the proportion of patients with these records, categorized by place and cause of death, along with an existing measure indicating palliative care needs. The proportion of people with a GP record of specialist palliative care was 4-5% on average, higher for those who died of cancer or died in a hospice. Advance care planning records increased from 19% to 27% (barring a decrease following the onset of the Covid-19 pandemic) driven in large part by increases for patients who died in care homes. Advance care planning and recording of palliative care needs were plausible measures to track changes in care, unlike the specialist palliative care measure where recorded use was sparse. Improved coding in primary care records would improve reliability of measures. Key messagesO_LIQuality of end-of-life care is traditionally measured by how patients use health services (for example emergency department attendances) C_LIO_LIWe used routine GP health records to track aspects of end-of-life care quality which matter to patients and discuss the impact of the covid-19 pandemic on these quality measures C_LIO_LIA new measure of advance care planning and the existing palliative care needs measure could be used to track end of life care delivered in the community C_LIO_LIThe measure of specialist palliative care was sparsely coded and unlikely to be useful unless coding and data linkage between GP and other systems improves C_LI

Objectives: Endometriosis affects approximately 10% of reproductive age women worldwide, yet care pathways remain fragmented and treatments have limitations. This study aimed to identify and categorize key stakeholders in endometriosis care in Ireland, assess their influence and interest in the digital health initiative, and identify drivers and barriers affecting uptake of innovative approaches to care. Methods: A virtual stakeholder mapping workshop was conducted with participants from healthcare, policy, education, technology, academia, and patient communities. Using a structured MS Teams Whiteboard, participants generated a stakeholder list, positioned stakeholders on an Influence-Interest Matrix, and provided qualitative insights on factors enabling or constraining engagement with digital health innovation. Results: Stakeholders were distributed across all four quadrants of the matrix. High-interest/high-influence stakeholders included the HSE, specialist centres, general practitioners, and the Endometriosis Association of Ireland. High-interest/low-influence groups comprised patients, families, and online communities, while policymakers, hospital managers, and the education sector were identified as high-influence but low-interest actors. Key drivers included strong patient advocacy, institutional support such as engagement from the HSE, and growing awareness of digital health tools. Major barriers encompassed prolonged diagnostic delays, resource constraints, gaps in clinical knowledge, technology anxiety, and challenges sustaining engagement. Conclusions: Stakeholder mapping provided an evidence-informed foundation for the VendoR project, revealing engagement gaps and leverage points critical for improving endometriosis care innovation. The findings highlight the need for intentional, well-resourced strategies that elevate patient voices, address systemic barriers, and ensure balanced representation, supporting the co-design, co-creation, and co-production of digital health interventions for sustainable, patient-centred care.

BackgroundMedical oxygen is an essential medicine that is often unavailable for patients when they need it. We explored if Outsourced Oxygen to the Bedside (O2B) pilots, where private providers deliver a package of services, were successful in ensuring reliable oxygen access at the patient bedside. MethodsWe conducted a sequential explanatory mixed-methods assessment of O2B pilots in Kenya, Nigeria, India, Tanzania, and Uganda from September 2024 - January 2025. A quantitative cross-sectional facility audit described facility contexts, tested equipment functionality and assessed healthcare worker (HCW) oxygen knowledge. Qualitative interviews with HCWs and managers explored experiences of O2B pilots. ResultsWe studied 28 of the 80 facilities participating in the pilots, 179 HCWs completed the knowledge survey, and 59 qualitative interviews were conducted. In the audit, we found O2B provided oxygen equipment more functional and usable than non-O2B equipment: 49.0% vs 30.1% (p-value<0.001) for cylinders, 82.9% vs 20.3% (p-value<0.001) for concentrators, and 84.0% vs 70.0% (p-value=0.172) for pulse oximeters. Overall, 21.8% (39/179) of HCWs had received training from O2B providers, and their oxygen knowledge was slightly higher than those who had not (mean score 15.3/24 vs 13.9/24, p-value=0.002). Qualitative interviews highlighted positive changes in oxygen access and the ability to treat patients, but also mixed understandings of the O2B services being provided, and requests for additional services. ConclusionO2B pilots appear to improve medical oxygen access, with effective maintenance and repair services being a key mechanism. However, tailoring to local needs and remaining gaps in HCW capacity need to be addressed.

Purpose: High clinical workload is associated with worse patient and hospital outcomes and is a well-established driver of clinician burnout. Trainees may be particularly exposed, shouldering both clinical and educational responsibilities. Evidence-based work design offers a data-driven approach to healthcare work but relies on robust workload measurements. Trainee workload remains poorly characterized, as commonly used metrics (e.g., duty hours, patient census) overlook cognitive and contextual dimensions. This pilot evaluated the feasibility of combining survey-based and electronic health record (EHR) data to characterize internal medicine (IM) trainee workload. Methods: A pilot study was conducted including IM and Medicine-Pediatrics residents (postgraduate years 1-4) between March 31 and June 22, 2025. Participants completed daily surveys during a seven-day inpatient schedule assessing workload and work experience domains, including environment, professional fulfillment, psychological safety, autonomy, and rounding experience, using validated instruments where available. Concurrently, EHR data captured chart review, documentation, orders, and secure messaging activity. Associations between survey and EHR data were assessed. Results: Among 37 eligible residents, 28 (76%) participated in the pilot capturing 166 shifts. Trainees spent 4.4 +/- 1.6 (mean +/- SD) minutes completing daily surveys and 8.6 +/- 2.3 minutes completing the final survey. Trainees reported working 11.6 +/- 1.0 hours/day and a median census of 9.0 (IQR 6.0-11.0). NASA-TLX score was 50.8 +/- 12.6. Positive shift ratings were associated with lower NASA-TLX scores and perceived rounding length. First-to-last EHR login duration was 15 +/- 2 hours/day, and EHR data showed 204 +/- 46 active minutes/day. Login duration correlated with self-reported hours (r=0.43, p<0.0001), and notes signed correlated with self-reported team (r=0.19, p=0.013) and personal census (r=0.34, p<0.0001). Conclusions: Integrating survey-based and EHR-derived workload measures provides multidimensional insight into trainee work. This novel approach supports scalable measurement and evidence-based work design interventions to improve trainee well-being, education, and clinical efficiency.

BackgroundOxycodone is widely prescribed for managing acute pain in emergency departments (ED), but the appropriateness of this prescription is not fully established. Although concerns about opioid misuse and dependence drive efforts to reduce inappropriate prescribing, there is increasing recognition of the importance of adequate pain management. Therefore, it is essential to develop appropriate prescribing criteria that balance the risks and benefits of opioids, ensuring their benefits are maximised while minimising potential harm. ObjectiveFollowing the recommended format for a research protocol paper, this protocol describes the process and methods used to develop evidence-based criteria for oxycodone prescribing in the ED, informed by scientific evidence and expert clinical judgment, using the RAND/UCLA Appropriateness Method. MethodThe process will be carried out in sequential stages. First, scope and key terms will be defined, and then a targeted literature review will be conducted to synthesise available evidence. Subsequently, based on this synthesis and the investigator teams clinical insights, clinical scenarios will be developed in collaboration with field experts. A multidisciplinary panel comprising specialists in emergency medicine, emergency nurses, and pharmacists will evaluate these scenarios in two rounds. Each scenario will be rated on a 1-9 scale, where 1 indicates that harm outweighs benefit and 9 indicates that benefit outweighs harm. The median rating score will fall between 1 and 9, where 1-3 without disagreement is inappropriate, 4-6 without disagreement is uncertain, and 7-9 without disagreement is appropriate. Disagreement is defined as at least three experts scoring in both extremes. Final scenario ratings will be presented according to their assessed appropriateness and used to inform appropriateness criteria for prescribing oxycodone in the adult ED. ConclussionThe RAND/UCLA Appropriateness Method offers a systematic and evidence-informed framework for developing prescribing criteria to support the appropriate use of oxycodone in adult ED.

Safety is a foundational concern in adolescent behavioral health crisis units (BHCUs), where therapeutic care must be delivered in complex, rapidly evolving environments. However, limited research has explored how key personnel involved in shaping the environment of care in such units, such as clinicians and healthcare designers, understand and prioritize safety. To address this gap, one-hour, online semi-structured interviews were conducted with a panel of experts (N = 13) at a national level in the U.S., comprising of eight designers (healthcare designers and medical planners) and five clinicians (psychologists and psychiatric nurses) actively involved in designing or construction of BHCUs or providing care in these units for adolescent patients in the past five years. The interviews were recorded, transcribed verbatim, and analyzed via MAXQDA (2024) for qualitative content analysis. Analysis of interviews revealed 592 codes forming four preliminary categories related to safety in adolescent BHCUs: 1) Barriers and facilitators to patient safety and comfort (f = 52%), 2) Care processes and clinical workflows (f = 21%), 3) Care outcomes (f = 19%), and 4) Laws, regulations, and guidelines (f = 7%). Findings highlighted several points of divergence in clinicians versus designers perception of safety related to environmental features, such as nursing station designs, patients access and control over unit features, and furniture type or layout in the unit. Results also showed differences in understanding care processes and outcomes related to safety among the two groups. Addressing such discrepancies can contribute to the development of safer BHCUs that support adolescents healing.

BackgroundMost births worldwide (>80%) occur in health care facilities, yet 2.3 million newborns die annually. If the know-do gap between evidence and implementation was closed, an estimated 752,000 newborn deaths could be prevented per year. To bridge this gap, we describe the co-design of the Implementation Toolkit for Small and Sick Newborn Care (Newborn Toolkit), a web platform and linked community of global implementers, facilitated by NEST360 and UNICEF. The Newborn Toolkit enables access to practical, curated resources, including tools for peer learning and adaptation to country contexts. MethodsA systematic three step process was followed. Step 1) Structure: We used an organising framework of WHO and UNICEF ten core components for health systems strengthening. We then reviewed relevant knowledge management platforms to identify elements facilitating user engagement. Step 2) Content: >300 implementers collated publications and tools for ten core components. Step 3) Refining and building community: User data analytics and surveys plus direct feedback from the global communities of practice provided data to improve website and webinar content. ResultsStep 1) Structure: In 2020, the Newborn Toolkit website structure was co-designed based on the ten core components. Step 2) Content: Working groups, organised by core components, collated over 1,100 resources in 15 languages. Step 3) Refining and building community: Cross-country learning was facilitated through 45 webinars with multi-disciplinary speakers from all continents including caregivers, clinicians, non-governmental organisation representatives, engineers, and data scientists. French language translation and engagement was added between 2023-2025. Unique user counts increased with 28,146 in 2023 to 62,561 in 2025 from 198 countries and territories. The most viewed content includes WHO guidelines, neonatal floor plans, the ABC device costing tool, and data tools. ConclusionsGiven the urgency for accelerated progress for newborn survival by 2030, rapid implementation of proven solutions is needed. It is crucial that implementers can access evidence and tools to adapt for their specific context, rather than "reinventing the wheel". Systems change is complex, requiring novel approaches to make it doable, such as standard, simplified action pathways available on the Newborn Toolkit. Gaps to address include evidence availability in multiple languages. KEY FINDINGSO_LIWHAT WAS KNOWN? O_LI2.3 million neonatal deaths are estimated annually and 65 countries are at-risk of missing Sustainable Development Goal 3.2 of reducing the number of neonatal deaths to less than 12 per 1,000 live births by 2030 C_LIO_LIThere exists a know-do gap in global newborn health referring to the inability to translate evidence, what is known to work, into practice to improve health outcomes for WHO-UNICEF level-2 Small and Sick Newborn Care C_LIO_LIFrameworks based on country experiences have been created to guide health systems strengthening such as the WHO/UNICEF core components; however, operationalisation is needed C_LIO_LIEvidence, guidelines, and resources for Small and Sick Newborn Care were available; however, there existed a gap in knowledge management platforms dedicated to enabling evidence-based implementation of health systems strengthening interventions in low-resource settings C_LI C_LIO_LIWHAT WAS DONE THAT IS NEW? O_LIWe co-designed a knowledge management platform for resources including tools, readings, and case studies to bridge the know-do gap for Small and Sick Newborn Care in low-resource settings C_LIO_LIContent and resources on the site were organised according to the ten WHO/UNICEF core components for health systems strengthening plus infection prevention and control C_LIO_LIThis platform was operationalised and scaled by linking to, and engaging with, a global community of practice C_LIO_LIWe applied a continuous learning and feedback integration approach to develop and refine content, enable accessibility including by language, and tailor engagement initiatives to implementer needs informed by website user and webinar data analytics C_LI C_LIO_LIWHAT WAS FOUND? O_LIThe platform hosts over 1,100 tools and readings with resources available in 15 languages C_LIO_LIBetween 2021-2025, this platform had 157,452 unique users, from 198 countries and territories C_LIO_LI45 webinars were hosted between 2022-2025 showcasing implementation case studies and facilitating cross-country learning C_LIO_LIKnowledge management and targeted engagement can enable uptake of information by organising content in practical, digestible, and feasible formats C_LI C_LIO_LIWHAT NEXT? O_LIThe know-do gap in Small and Sick Newborn Care needs to be closed. Providing up-to-date, relevant evidence that adapts to emerging knowledge and local learning, alongside leadership and financial inputs, could facilitate quality care delivery through data-driven decision making C_LIO_LIBridging language barriers, through content translation, is a priority and crucial to enable wider access to up-to-date evidence C_LI C_LI