Risk Management and Healthcare Policy

Background A culture of patient safety is a significant determinant of healthcare quality and the prevention of patient harm. The objective of this study was to evaluate patient safety culture among healthcare workers at a tertiary-care hospital in India using the Indian-adapted Hospital Survey on Patient Safety Culture (I-HSOPSC 2.0). Method The survey was descriptive and cross-sectional, carried out among 96 healthcare practitioners, comprising 32 doctors, 32 nurses, and 32 allied health professionals. Also, a validated version of the Hospital Survey on Patient Safety Culture (I-HSOPSC 2.0) was used to measure patient safety culture in India. Descriptive statistics, Shapiro-Wilk test, Kruskal-Wallis test, Fishers exact test, and positive response rate analysis were used for the data analysis. Result The overall patient safety culture score was 3.72 {+/-} 0.52, indicating a positive view of patient safety culture. In terms of domains, Communication about Errors, Management Support for Patient Safety, and Teamwork scored highest, while Staffing, Work Pace, and Response to Errors scored lowest. Considerable discrepancies were observed across professions, with allied health professionals giving more favourable answers than nurses. Conclusion Overall, the culture around patient safety was good, but areas such as staffing, pace of work, and error response need targeted attention to sustain patient safety and improve the quality of care in healthcare services.

Background: Chronic pharmaceutical stock outs hinder Universal Health Coverage in Ethiopia. To address this, the Ministry of Health introduced the electronic Logistics Management Information System for inventory visibility and Auditable Pharmaceutical Transactions and Services for financial management. However, no national study has tested their combined impact. This study evaluated the individual and synergistic effects of electronic Logistics Management Information System and Auditable Pharmaceutical Transactions and Services on essential commodity availability across Ethiopian public healthcare facilities. Methods; We conducted a secondary analysis of the 2024/2025 Ethiopian Service Provision Assessment dataset utilizing 1245 public facilities nested within 125 clusters. The primary outcome was optimal essential commodity availability (zero stock outs and 100% tracer commodity presence). A two-level mixed-effects logistic regression model with an interaction term evaluated synergy, reporting Adjusted Odds Ratios with 95% Confidence Intervals. Results; Overall optimal availability was 54.2% (95% CI; 51.4%-57.0%). Implementation rates were 41.2% for eLMIS, 38.2% for APTS and 26.5% for dual implementation. Facilities using eLMIS alone (AOR = 2.15; 95% CI: 1.52-3.04) and APTS alone (AOR = 1.82; 95% CI; 1.28-2.58) showed higher security. Dual implementation showed a profound synergistic effect (AOR = 4.32; 95% CI; 3.25-5.74, p < 0.001). Positive predictors included functional cold chains (AOR = 2.08), qualified staffing (AOR = 1.68), hub proximity (AOR = 1.58) and urban settings (AOR = 1.95). The model explained 66.2% of regional variance. Conclusion; Dual implementation of electronic Logistics Management Information System and Auditable Pharmaceutical Transactions and Services creates a powerful synergistic impact on pharmaceutical availability. Synchronized national scale-up and cold chain investments are urgently needed to achieve supply chain resilience and Universal Health Coverage in Ethiopia.

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.

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.

Background. Regulatory pressure to avoid confusingly similar drug names appears to have pushed manufacturers to coin more distinctive proprietary names, but no one has quantitatively analyzed this trend. Objective. To determine whether proprietary drug names became more orthographically distinctive (unusual in spelling) over time. Methods. We examined 1,321 US Food and Drug Administration (FDA) new molecular entity (NME) names (1985-2024), 2,769 FDA Orange Book trade names (1982-2026), 177,337 US pharmaceutical trademarks (1980-2026), and 1,273 generic names (1982-2025). Compared to prior names (including those already marketed) and ordinary English, we scored each name's character trigram (three-letter sequence) surprisal (statistical unexpectedness) and its edit-distance similarity to the closest existing names. Linear regression tested time trends, controlling for name length. Results. Mean NME trigram surprisal rose in every decade between the 1980s and 2020s, from 7.21 to 8.50 nats (natural-logarithm units, higher meaning less predictable), an 18% increase (b = 0.038, p < .001, R2 = 0.34). Half of 2020s names (7% in the 1980s) contained a letter sequence found in no common English word (e.g., Jesduvroq, Omvoh). Nearest-neighbor similarity fell after the early 1990s. Trademark data showed the same trend (b = 0.016, p < .001). Generic names showed a weaker trend (b = 0.011, R2 = 0.063). Conclusions. Over four decades, drug names became more orthographically distinctive, consistent with namespace crowding, deliberate efforts to avoid confusing names, and branding strategy. Because unfamiliar letter sequences can introduce other error pathways, increased distinctiveness does not necessarily imply improved safety.

Background: Knowledge translation (KT) is essential for ensuring that research evidence informs policy and practice. However, little is known about researchers' intentions to engage in KT activities or their relationship with conventional bibliometric indicators. This study aimed to (1) assess researchers intentions to engage in KT activities using a questionnaire informed by the Theory of Planned Behavior (TPB), and (2) examine the association between these intentions and individual bibliometric indicators. Methods: A cross-sectional survey was conducted among faculty members at Tehran University of Medical Sciences. A questionnaire informed by selected constructs of the TPB was developed to assess researchers intentions to engage in activities across the seven components the action cycle of Knowledge-to-Action (KTA) framework. The instrument was validated through several rounds of expert review and then with a sample of potential participants. Bibliometric indicators (H-index, Number of Publications, Number of Citations, First-Author Publications, Corresponding Authorship, International Publications and Self-Citations) were extracted from the national academic registry. To assess representativeness, bibliometric characteristics of respondents were compared with those of a random sample of non-respondents drawn from the same registry. Confirmatory Factor Analysis (CFA) validated the intention construct, and Structural Equation Modeling examined associations with demographic and bibliometric variables. Results: A total of 143 researchers participated. Intention scores were highest for adapting knowledge to local contexts and identifying barriers and facilitators, and lowest for monitoring and sustaining knowledge use. CFA supported a unidimensional intention construct with favorable model-fit indicators. No bibliometric indicator was significantly associated with KT intention. Age was the only significant predictor. Respondents had stronger bibliometric profiles than non-respondents, indicating potential non-response bias. Conclusions: Researchers reported relatively strong intentions to engage in KT, but these intentions were not associated with conventional bibliometric indicators. Age was the only significant predictor. Overall, findings suggest that traditional academic metrics may not reflect KT intentions and highlight the need to strengthen institutional incentives for KT.

Background: Digital mental health applications offer scalable pathways to expand mental healthcare access in low and middle-income countries, yet limited evidence exists on factors predicting willingness to use such applications in South Asia. This study examined associations between digital mental health literacy (DMHL), Technology Acceptance Model (TAM) constructs, mental health symptoms, and willingness to use smartphone-based mental health applications among adults in Bangladesh. Methods: Cross-sectional study conducted from February to June 2026 across urban (Dhaka), semi-urban (Chattogram), and rural (Sylhet) divisions of Bangladesh. Adults aged 18-60 years attending primary care facilities with smartphone access (n = 400) completed a face-to-face interview in Bangla assessing sociodemographic, depression (PHQ-9), anxiety (GAD-7), DMHL (6-item scale, = .762), TAM perceived usefulness (5-item, = .937) and ease of use (5-item, = .924), and willingness to use mental health applications (5-item scale, = .946). Hierarchical binary logistic regression examined associations with willingness (dichotomized at mean [&ge;]3.5). Results: Greater DMHL was associated with higher willingness (adjusted odds ratio [aOR] = 1.24, 95% CI: 1.11-1.38). Both perceived usefulness (aOR = 1.29, 95% CI: 1.18-1.41) and perceived ease of use (aOR = 1.17, 95% CI: 1.07-1.28) independently predicted willingness. Anxiety symptoms were positively associated (aOR = 1.08 per 1-point increase, 95% CI: 1.01-1.15), whereas depression symptoms, age, and sex were not independently significant after adjustment for other variables. Conclusions: Digital literacy, perceived utility of technology, and symptom-specific phenomenology but not demographics alone are associated with willingness to use digital mental health applications. Building DMHL, optimizing the usefulness and usability of the app, and overcoming implementation barriers should all be given priority.

Bangladeshi immigrants are a rapidly growing U.S. immigrant population, yet little is known about how pre-migration healthcare experiences shape healthcare use after migration. This qualitative study explored how healthcare norms from Bangladesh influence the health-seeking behaviors of Bangladeshi immigrants in the U.S., the barriers and facilitators they encounter, and their perceptions of care quality. Semi-structured interviews were conducted with 29 Bangladeshi-born adults living in the U.S. from September 2020 to January 2021 and analyzed using the constant comparative method. Participants described healthcare expectations shaped by the healthcare system of Bangladesh, which is mostly out-of-pocket and resource-limited, including symptom-driven rather than preventive care, self-treatment, and family-based caregiving. In the U.S., they faced barriers such as insurance confusion, long waits, difficulty establishing care, coverage disruptions, financial concerns, and language challenges. While participants valued culturally and linguistically concordant care, preferences for Bangla-speaking or co-ethnic providers varied, especially when perceived quality was low. Community networks, online information, self-education, and self-advocacy helped facilitate care. Provider communication strongly shaped perceptions of U.S. healthcare: feeling heard, respected, and well-informed promoted trust, while dismissal or delayed diagnosis led to skepticism and avoidance. These findings suggest that healthcare engagement of Bangldeshi immigrants is shaped by both structural barriers and pre-migration norms. Improving access will require attention to subgroup-specific histories, insurance navigation, language access, and the relational quality of care.

Background: Workplace discrimination and violence against health workers including sexual harassment is a societal problem worldwide. We aimed to assess the frequency, predictive factors, and effects of sexual harassment using a nationwide survey of physicians working in Switzerland. Materials and Methods: We conducted a self-administered questionnaire survey of physicians working in Swiss healthcare institutions. The questionnaire assessed experiences of sexual harassment at work, including frequency, types, and sources of harassment. It also asked about the impact of sexual harassment, whether incidents were reported, and what actions were taken following a report. Results: Among the 1837 physicians that participated in the survey, 575 (31.3%) had experienced sexual harassment at least once during their career. Among those reporting sexual harassment, 39.1% of women and 13.2% of men had experienced harassment at least once in their job. Women reported more verbal harassment, while men reported more physical harassment. Women were also more likely to face both forms combined. The main sources of harassment were colleagues of the same profession (46.7%), patients (42.3%), and superiors (41.0%). The most frequently reported impacts included stress (60.1%), emotional exhaustion (34.7%), reduced motivation at work (30%), and considering leaving the job (7.5%). Gender-men was associated with a lower likelihood of experiencing harassment 0.24 (0.18 to 0.31), whereas working in the German-speaking region was associated with a slightly higher likelihood of having experienced sexual harassment at least once (OR 1.35, 95% CI:1.02-1.81). Conclusions: Sexual harassment is common among physicians in Swiss healthcare institutions. It adversely affects the mental health and career trajectories of both men and women yet remains widely underreported due to fears of reprisals and inaction. Institutions should effectively intervene to ensure that reported incidents result in appropriate actions, and that those who report them receive adequate protection from reprisals.

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 Chronic diseases are the leading causes of illness, disability, and death worldwide, with a disproportionate burden in low- and middle-income countries. Hospitalization is a critical outcome in chronic disease management, reflecting disease severity, treatment failure, and healthcare utilization. However, data on hospitalization burden and its associated factors among chronic disease patients in Ethiopia, are limited. This study aimed to determine the rate of hospitalization and its associated factors among patients with chronic diseases attending a tertiary hospital in Wolaita Zone, South Ethiopia. Methods A facility-based cross-sectional study was conducted among 321 patients with chronic diseases attending the chronic follow-up clinic at Wolaita Sodo University Comprehensive Specialized Hospital from November to December 2022. Consecutive recruitment was used, with unique medical record numbers tracked to prevent double recruitment. Data were collected through structured questionnaires and medical record review. Negative binomial regression was used to identify factors associated with hospitalization rate, with incidence rate ratios (IRR) and 95% confidence intervals (CI) reported. A p-value < 0.05 was considered statistically significant. Results Of the 321 participants, 66% reported at least one hospitalization while on treatment, with a mean of 1.70 {+/-} 1.81 hospitalizations per patient. Drug discontinuation was the most frequently documented reason for hospitalization (39.5%), followed by disease complications (22.3%) and infections (11.7%). Multimorbidity was prevalent, with the majority (59.8%) had 2-3 conditions, and a mean of 2.40 {+/-} 1.02 chronic diseases per patient. Male sex was associated with a higher hospitalization rate, while regular physical exercise was associated with a lower number of hospitalizations. Conclusion This study found a high burden of hospitalization among chronic disease patients, with drug discontinuation being the leading documented reason. Male sex and regular physical exercise were significantly associated highlighting the need for medication adherence support programs and structured exercise programs integrated into routine chronic disease care, as well as gender-sensitive interventions.

Introduction: Hospitals face increasing financial pressures. Hospital reimbursement is tied to the Case Mix Index (CMI). The CMI is a measure of complexity of care provided by the hospital and the total reimbursement is the CMI multiplied by a base pay factor, multiplied by the total number of discharges from the hospital. The few studies in the literature have involved logistically complex attempts to improve documentation. We sought to determine whether limited, structured chart review by surgeons can improve CMI in a multihospital system. Methods: We performed a prospective, observational study in a four-hospital academic medical system on all surgical patients from 10/2022 to 7/2026. Two clinically busy trauma surgeons performed limited structured chart reviews for select surgical patients. In the limited intervention period (1/2024-9/2024) this focused only on the trauma division. In the full intervention period (10/2024-7/2026) expanded to all surgical patients across the system. The main outcome was surgical case mix index (CMI). Results: A total of 35,695 patients were included (13,811 pre-intervention, 9,337 limited intervention, 12,547 full intervention). CMI increased significantly among surgical patients across the whole system (2.68 (95%CI 2.65-2.71) to 2.87 (95%CI 2.82-2.92) to 2.97 (95%CI 2.93-3.01), ANOVA p <0.001). Overall length of stay was unchanged among surgical patients across the whole system. The estimated increase in revenue per patient attributable to this intervention was $3,912 in surgical patients across the system. Conclusion: Having trauma surgeons review targeted surgical patients for high value documentation capture significantly enhanced the CMI and estimated revenue of surgical services across a multi-hospital integrated health system. Such documentation reviews may represent a practical method to improve hospital documentation and revenue.

Objective. To identify antimicrobial stewardship targets by triangulating provider knowledge and practice, government-facility prescribing indicators and patient-reported treatment experience in three districts of Chhattisgarh, India. Methods. We analysed three independently sampled cross-sectional components: a provider survey (171 providers), a World Health Organization and International Network for Rational Use of Drugs assessment (600 encounters at 20 government facilities) and patient exit interviews (371 consultations). We used descriptive indicators and multivariable ordinal or binary logistic regression. Findings. Among providers, 149 of 163 (91.4%) recognized antimicrobial resistance, but 131 of 163 (80.4%) reported providing antibiotics for colds or sore throats to at least some patients. Guideline familiarity was not associated with less frequent provision (adjusted common odds ratio [aOR], 1.13; 95% confidence interval [CI], 0.57-2.24; P=0.725). Government facilities prescribed antibiotics in 329 of 600 encounters (54.8%), with a facility range of 16.7-80.0%. In exit interviews, 131 of 142 informal-provider consultations (92.3%) involved a reported injection; informal providers accounted for 131 of 181 reported injections (72.4%). Clear or very clear instructions were associated with satisfaction (aOR: 13.66; 95% CI: 6.37-29.28; P<0.001). Conclusion. High awareness coexisted with frequent self-reported antibiotic provision, wide facility variation and sector-specific injection exposure. Stewardship programmes should diagnose local drivers before selecting interventions and prospectively evaluate adapted decision support, audit and feedback, independent drug information, informal-provider engagement and communication training.

Background: Hand hygiene is a key public health intervention for preventing infectious diseases, including respiratory and gastrointestinal infections. Although the COVID-19 pandemic improved awareness and compliance, sustained adherence remains a challenge, with evidence showing a decline in practice after outbreaks, particularly among young adults in high-contact settings such as universities. Therefore, this study aimed to assess the knowledge, attitudes, and practices of handwashing hygiene among university students at KCMC University, Moshi, Tanzania, in the post-COVID-19 era. Methods: A cross-sectional study was conducted among 380 students at KCMC University. Data were collected using a pretested structured questionnaire, which captured information on socio-demographic characteristics, knowledge, attitudes, and practices regarding handwashing hygiene. Data were analyzed using descriptive and inferential statistics. Associations between variables were assessed using logistic regression and multivariable analysis, and a p-value of <0.05 was considered statistically significant. Results: A total of 380 students participated in the study, with a mean age of 23.5 {+/-} 3.5 years. More than half 209 (55.0%) were aged 18-23 years, while 203 (53.4%) were female. Most participants had access to hand hygiene facilities 338 (88.9%). 338 (88.9%) participants had good knowledge of hand hygiene but attitudes were mostly negative 193 (50.8%), and practices were suboptimal, with 201 (52.9%) showing poor hand hygiene practices. Good hand hygiene knowledge was associated with access to hand hygiene facilities (AOR=2.84, 95% CI: 1.25-6.42, p=0.012) and formal training on hand hygiene (AOR=3.48, 95% CI: 1.24-9.76, p=0.018). Positive attitudes were associated with being in the fourth year or above (AOR=2.12, 95% CI: 1.16-3.89, p=0.015). Good hand hygiene practices were associated with access to hand hygiene facilities (AOR=2.67, 95% CI: 1.18-6.01, p=0.018) and formal training on hand hygiene (AOR=2.98, 95% CI: 1.19-7.48, p=0.020). Conclusion: Although knowledge and awareness of handwashing hygiene were generally high among university students, inconsistencies between knowledge and actual practices were observed in the post-COVID-19 era. Strengthening health education programs and ensuring continuous access to handwashing facilities may improve adherence to proper hand hygiene practices among university students.

Background Medicine shortages are monitored within national borders, but complementarity across national markets is poorly characterised. Objective To characterise medicines supplied through South Korea's national access programme and to quantify this complementarity between South Korea and Italy. Methods In this cross-sectional study, we linked shortage records from the Italian Medicines Agency and Korean Ministry of Food and Drug Safety, Korea Orphan and Essential Drug Center supply notices, and national reimbursement lists. The primary outcome was the proportion of shortage configurations with a reimbursed counterpart in the partner country, identified by normalised ingredient, pharmaceutical form, and route, and not recorded as withdrawn or in shortage. The primary analysis covered Jan 1 to June 30, 2026, and the secondary analysis covered 2023-26. Results Among 341 formulations supplied through the Korean national access programme, 242 (71.0%) lacked domestic marketing authorisation at first observed supply or were supplied after market withdrawal. Of 338 Italian shortage configurations in the first half of 2026, 228 (67.5%) had an available reimbursed Korean counterpart; over 2023-26, 332 of 549 (60.5%) did. Conversely, 27 of 47 Korean configurations (57.4%) had such an Italian counterpart; over 2023-26, 93 of 184 (50.5%) did. In both directions, ingredients on EU critical or Korean essential medicine lists more often had a cross-border match than unlisted ingredients. Conclusions About half of shortage or access-gap medicines had a potentially available reimbursed counterpart in the other country. Cross-national linkage of medicine data may help identify potential counterparts, although these require regulatory, clinical, and procurement review.

Background: Lean Healthcare has been adopted as an approach to reducing waste, enhancing process efficiency, and optimizing clinical and administrative workflows. However, empirical evaluations aimed at establishing a causal relationship between Lean Healthcare interventions and outcomes remain limited. This evidence gap is particularly pronounced in the context of large-scale implementations in low- and middle-income countries, where more efficient allocation could yield substantial improvements in population health. Methods: We conducted an impact evaluation study employing a staggered difference-in-differences approach to estimate the effects of the Lean Healthcare in Emergency Departments (ED) initiative in the Brazilian context. The intervention was implemented between January 2017 and December 2025 across 309 hospitals. We analyzed hospital-level indicators of the number of hospitalizations and the average length of stay (in days) among patients admitted through urgent or emergency pathways. Results: Our estimates suggest that the intervention was associated with an average increase of 38.6 admissions per hospital per month (p = 0.033), corresponding to approximately a 5.9% increase relative to the monthly admission volume. We also observed a reduction of 0.184 days in the average length of stay (p = 0.058), equivalent to an approximately 3.0% decrease in hospitalization time. These effects exhibited distinct temporal dynamics: the effect on the number of hospitalizations emerged gradually and increased with the duration of the intervention, whereas the reduction in length of stay became evident earlier. Conclusion: This study provides evidence of a causal effect of Lean Healthcare implementation in emergency departments on operational performance. The simultaneous increase in admissions and reduction in length of stay suggests improved bed productivity and effective capacity without expanding physical infrastructure. These findings support the use of flow-management methodologies as an effective strategy for mitigating emergency department overcrowding while increasing service capacity.

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.

Background: Herbal medicinal products are widely used in Ghana; however, adverse drug reaction (ADR) reporting associated with these products remains limited, posing challenges to pharmacovigilance and medicine safety surveillance. This study assessed trends in herbal medicine-related ADR reporting, determined the prevalence and factors associated with ADR reporting among herbal practitioners, and explored barriers to ADR reporting in Ghana. Methods: A mixed-methods study involving secondary pharmacovigilance data review, an analytic cross-sectional survey, and qualitative in-depth interviews was conducted. Secondary data on herbal medicine-related ADR reports submitted to the Ghana Food and Drugs Authority (FDA) between 2014 and 2024 were reviewed descriptively. The cross-sectional survey involved 271 herbal practitioners selected through multi-stage probability sampling across seven districts in the Greater Accra Region. Quantitative data were analysed using descriptive statistics and logistic regression in IBM SPSS Statistics version 26. The qualitative component involved 15 purposively selected participants, and thematic analysis was conducted using MAXQDA 2020. Results: A total of 117 herbal medicine-related ADR reports met the inclusion criteria and were analysed from the Ghana FDA pharmacovigilance database between 2014 and 2024. Among 271 surveyed herbal practitioners, 11.8% (95% CI: 8.0-15.6) reported submitting at least one ADR report during the preceding 12 months. In multivariable analysis, lack of ADR reporting forms or job aids (aOR = 0.11, 95% CI: 0.04-0.31) and lack of exposure to Ghana FDA ADR reporting guidelines (aOR = 0.09, 95% CI: 0.03-0.32) were independently associated with lower odds of ADR reporting. Qualitative findings identified causal uncertainty, inadequate training, weak reporting systems, commercial interests, and limited regulatory support as major barriers to reporting. Conclusion: ADR reporting associated with herbal medicinal products was limited within the national pharmacovigilance system and among surveyed herbal practitioners. System-level barriers, particularly limited access to reporting tools and FDA reporting guidance, were associated with lower reporting. Strengthening pharmacovigilance infrastructure, improving practitioner training, and increasing access to reporting tools may improve herbal medicine safety surveillance

Menstrual health remains a neglected public health challenge in India, where persistent stigma, incomplete education, inadequate sanitation, and limited access to menstrual health resources can adversely affect health and social participation. Institution-based educational programs represent an underexplored opportunity to improve menstrual health literacy while promoting more inclusive discussions surrounding menstruation. Bridging this gap, an exploratory, prospective educational evaluation was conducted at a hospital in Coimbatore, Tamil Nadu and an engineering college in Wayanad, Kerala. Anonymous pre- and post-course surveys assessed menstrual health knowledge, attitudes, practices, perceived barriers, and perspectives on emerging digital health technologies. Quantitative responses were summarized descriptively, and open-ended responses were reviewed to identify recurring perspectives that contextualized the quantitative findings. The standardized educational program integrated evidence-based menstrual health education with discussions of bioengineering and wearable technologies. Eighty-three participants completed the pre-course survey, 68 attended the educational program, and 20 completed the post-course survey. Because responses could not be linked at the individual level, the survey cohorts were compared descriptively. At baseline, 80 of 82 respondents (97.6%) recognized menstruation as a biological process, yet only 38 of 82 (46.3%) indicated that it was not solely a woman's issue. The mean agreement that menstruation remained taboo was 7.44 of 10 (SD 1.99; n=78), and 51 of 77 respondents (66.2%) reported that they or others avoided activities during menstruation. Painful periods were identified as a barrier by 56 of 67 respondents (83.6%), and 18 of 67 (26.9%) considered institutional or community toilets insufficiently clean and private for menstrual management. Open-ended responses illustrated how pain, fear of leakage, stigma, and inadequate facilities constrained participation in school, physical activity, and social life. These findings document a marked gap between basic biological recognition and the social normalization and practical support of menstruation in two South Indian institutions, and support further evaluation of gender-inclusive, context-responsive menstrual health education using paired assessments, stronger follow-up, comparison groups, and long-term outcomes.

Background Drug-resistant tuberculosis (DR-TB) remains a major problem in Indonesia, with a significant low treatment initiation rate. This study identifies factors influencing treatment initiation and assess the impact of delay on patient outcomes. Methods We conducted a mixed-methods study using a parallel convergent design. The quantitative component analyzed the Tuberculosis Information System (TBIS) data from three hospitals in Jakarta and Bogor from January 2022 to December 2023. The qualitative component involved in-depth interviews and Focus Group Discussions (FGD) with DR-TB patients, healthcare workers, patient supporters, and program managers. Results Among 1,665 people with DR-TB included in this study, we found a pre-treatment attrition rate of 6.4%. We identified two factors of pre-treatment attrition: prior TB treatment (aOR=1.7, 95%CI 1.082-2.671) and distance to hospital (aOR=1.9, 95%CI: 1.136-3.180). Conversely, referred patients, treatment in suburban areas, and people with rifampicin-resistant (RR)-TB were 85%, 82%, and 63% less likely to experience attrition, respectively. Qualitative findings identify patient, social, and health system barriers to the treatment initiation, and alternative remedies emerged as a coping mechanism. Conclusion Strengthening referral systems, decentralizing care, and addressing socio-economic barriers are critical for ensuring timely DR-TB treatment initiation.