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BACKGROUND: Healthcare worker (HCW) anxiety and depression worsened during the pandemic, prompting the expansion of digital mental health platforms as potential solutions offering online assessments, access to resources and counselling. The use of these digital engagement tools may reflect tendencies and trends for the mental health needs of HCWs. OBJECTIVES: This retrospective, cross-sectional study investigated the association between the use of an online mental health platform within a large academic health system and measures of that system's COVID-19 burden during the first 3 years of the pandemic. METHODS: The study investigated the use of Cobalt, an online mental health platform, comprising deidentified mental health assessments and utilisation metrics. Cobalt, serves as an online mental health resource broadly available to health system employees, offering online evidence-based tools, coaching, therapy options and asynchronous content (podcasts, articles, videos and more). The analyses use validated mental health assessments (Generalised Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9) and post-traumatic stress disorder (PTSD)) alongside publicly available COVID-19 data. Statistical analyses employed univariate linear regression with Stata SE Statistical Software. RESULTS: Between March 2020 and March 2023, 43 308 independent user sessions were created on Cobalt, a majority being anonymous sessions (72%, n=31 151). Mental health assessments, including PHQ-4, PHQ-9, GAD-7 and primary care-PTSD, totalled 9462 over the time period. Risk for self-harm was noted in 17.1% of PHQ-9 assessments. Additionally, 4418 appointments were scheduled with mental health counsellors and clinicians. No significant associations were identified between COVID-19 case burden and Cobalt utilisation or assessment scores. CONCLUSION: Cobalt emerged as an important access point for assessing the collective mental health of the workforce, witnessing increased engagement over time. Notably, the study indicates the nuanced nature of HCW assessments of anxiety, depression and PTSD, with mental health scores reflecting moderate decreases in depression and anxiety but signalling potential increases in PTSD. Tailored resources are imperative, acknowledging varied mental health needs within the healthcare workforce. Ultimately, this investigation lays the groundwork for continued exploration of the impact and effectiveness of digital platforms in supporting HCW mental health.

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OBJECTIVE: Learning from adverse outcomes in health and social care is critical to advancing a culture of patient safety and reducing the likelihood of future preventable harm to service users. This review aims to present an overview of all clinical claims finalised in one calendar year involving publicly funded health and social care providers in Ireland. DESIGN: This is a retrospective observational study. The Clinical Risk Unit (CRU) of the State Claims Agency identified all service-user clinical claims finalised between 1 January 2017 and 31 December 2017 from Ireland's National Incident Management System (n=713). Claims that had incurred financial damages were considered for further analysis (n=356). 202 claims underwent an in-depth qualitative review. Of these, 57 related to maternity and gynaecology, 64 to surgery, 46 to medicine, 20 to community health and social care and 15 related to children's healthcare. RESULTS: The services of surgery and medicine ranked first and second, respectively, in terms of a number of claims. Claims in maternity services, despite ranking third in terms of claims numbers, resulted in the highest claims costs. Catastrophic injuries in babies resulting in cerebral palsy or other brain injury accounted for the majority of this cost.Diagnostic errors and inadequate or substandard communication, either with service users and/or interprofessional communication with colleagues, emerged as common issues across all clinical areas analysed. Quantitative analysis of contributory factors demonstrated that the complexity and seriousness of the service user's condition was a significant contributory factor in the occurrence of incidents leading to claims. CONCLUSION: This national report identifies common issues resulting in claims. Targeting these issues could mitigate patient safety risks and reduce the cost of claims.

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Introduction The Emergency Severity Index (ESI) stratifies emergency department (ED) patients for triage, from "most acute" (level 1) to "least acute" (level 5). Many EDs have a split flow model where less acute (ESI 4 and 5) are seen in a fast track, while more acute (ESI 1, 2, and 3) are seen in the acute care area. A core principle of emergency medicine (EM) is to attend to more acute patients first. Deliberately designating an area for less acute patients to be initially assessed quickly by a first provider might result in them being seen before more acute patients. This study aims to determine the percentage of less acute patients seen by a provider sooner after triage than more acute patients who arrived within 10 minutes of one another. Additionally, this study compares the fast track and acute care areas to see if location affects triage-to-provider time. Methods A random convenience sample of 252 ED patients aged ≥18 was taken. Patients were included if their ESI was available for the provider during sign-up. Patients were excluded if they were directly sent to the ED psychiatric area or attended to by the author. We collected data on the ESI level, time stamps for triage and first provider sign-up, and the location to which the patient was triaged (fast track vs. acute care). Paired patients' ESI levels, locations, and triage and first provider sign-up times were compared. Results  The study included 126 pairs of patients. There was a statistically significant difference in triage-to-provider times for paired ESI 2 vs. 3 patients (60.5 vs. 35.5 minutes, p = 0.0007) and overall paired high- vs. low-acuity patients (55 vs. 39.5 minutes, p = 0.004). However, in 34.8% of paired ESI 2 vs. 3 patients, the ESI 3 patient was seen prior to the paired ESI 2 patient, and in 39.4% of overall paired high vs. low acuity patients, the less acute patient was seen before the more acute patient. Additionally, patients in the acute care area had significantly shorter median triage-to-provider times (~40 minutes) compared to those in the fast track area for ESI 2 (acute care) vs. ESI 3 (fast track) and overall high acuity (acute care) vs. low acuity (fast track). Nonetheless, approximately one-third of ESI 3 patients triaged to fast track were seen before ESI 2 patients triaged to the acute care area. Conclusion The split flow model reduces overall ED length of stay, improving flow volume, revenue, and patient satisfaction. However, it comes at the expense of the fundamental ethos of EM and potentially subverts the intended triage process. Although most more acute patients are seen by a provider sooner after triage than less acute patients, a substantial number are seen later, which could delay urgent medical needs and negatively impact patients' outcomes. Furthermore, patients triaged to acute care are, in general, seen sooner post-triage than identical-ESI-level fast track patients, suggesting fast track might not function as intended (for low-acuity patients to be quickly assessed and initiate diagnostic and treatment plans). We intend to follow this exploratory study with a more comprehensive, multivariate analysis that will consider confounding variables such as initial vital signs, how busy a provider was that day, etc. The future study will also examine patient outcomes to determine the impact on more acute patients of the split flow model and, in particular, on less acute patients being seen sooner by a first provider.

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BACKGROUND: The way that data are presented can influence quality and safety initiatives. Time-series charts highlight changes but do not clarify whether data lie outside expected variation. Statistical process control (SPC) charts make this distinction and have been demonstrated to be effective in supporting hospital initiatives. To improve the uptake of the SPC methodology by hospitals in England, a training intervention was created. The current study evaluates the effectiveness of that training against the background of a wider national initiative to encourage the adoption of SPC charts. METHODS: A parallel cluster randomised trial was conducted with 16 English NHS hospitals. Half were randomised to the training intervention and half to the control. The primary analysis compares the difference in use of SPC charts within hospital board papers in a postrandomisation period (adjusting for baseline use). Trainees completed feedback forms with Likert scale and open-ended items. RESULTS: Fifteen hospitals participated across the study arms. SPC chart use increased in both intervention and control hospitals between the baseline and postrandomisation period (29 and 30 percentage points, respectively). There was no statistically significant difference between the intervention and control hospitals in use of SPC charts in the postrandomisation period (average absolute difference 9% (95% CI -34% to 52%). In the feedback forms, 93.9% (n=31/33) of trainees affirmed learning and 97.0% (n=32/33) had formed an intention to change their behaviour. CONCLUSIONS: Control chart use increased in both intervention and control hospitals. This is consistent with a rising tide and/or contamination effect, such that the culture of control chart use is spreading across hospitals in England. Further research is needed to support hospitals implementing SPC training initiatives and to link SPC implementation to quality and safety outcomes. Such research could support future quality and safety initiatives nationally and internationally. TRIAL REGISTRATION NUMBER: NCT04977414.

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Radiographic quality control is an integral component of the radiology workflow. In this study, we developed a convolutional neural network model tailored for automated quality control, specifically designed to detect and classify key attributes of wrist radiographs including projection, laterality (based on the right/left marker), and the presence of hardware and/or casts. The model's primary objective was to ensure the congruence of results with image requisition metadata to pass the quality assessment. Using a dataset of 6283 wrist radiographs from 2591 patients, our multitask-capable deep learning model based on DenseNet 121 architecture achieved high accuracy in classifying projections (F1 Score of 97.23%), detecting casts (F1 Score of 97.70%), and identifying surgical hardware (F1 Score of 92.27%). The model's performance in laterality marker detection was lower (F1 Score of 82.52%), particularly for partially visible or cut-off markers. This paper presents a comprehensive evaluation of our model's performance, highlighting its strengths, limitations, and the challenges encountered during its development and implementation. Furthermore, we outline planned future research directions aimed at refining and expanding the model's capabilities for improved clinical utility and patient care in radiographic quality control.

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IMPORTANCE: Despite evidence that most upper respiratory infections (URIs) are due to viruses, antibiotics are frequently prescribed for this indication in the outpatient setting. Antibiotic stewardship strategies are needed to reduce adverse patient outcomes and staggering healthcare costs due to resistant infections that ensue from inappropriate prescriptions. OBJECTIVE: To determine if individual provider scorecards detailing antibiotic prescribing rates paired with educational resources reduce inappropriate antibiotic use for URIs in the outpatient primary care setting. DESIGN, SETTING AND PARTICIPANTS: This quality improvement project investigated the number of URI-coded office visits in the primary care setting over three consecutive influenza seasons, which resulted in an antibiotic prescription in Cooper University Healthcare's 14 primary care offices. We compared provider's individual prescribing patterns to their peers' average and created a scorecard that was shared with each provider over a series of intervention phases. Data were collected from a preintervention period (November 2017-February 2018), and two postintervention phases, phase I (November 2018-February 2019) and phase II (November 2019-February 2020). INTERVENTION: A personalised, digital scorecard containing antibiotic-prescribing data for URI-coded visits from the prior influenza season was emailed to each primary care provider. Prior to the subsequent influenza season, prescribers received their updated prescribing rates as well as peer-to-peer comparisons. In both phases, the scorecard was attached to an email with antimicrobial stewardship educational materials. MAIN OUTCOMES AND MEASURES: The primary outcome was a reduction in the number of inappropriate antibiotic prescriptions for URI-related diagnoses. The diagnoses were organised into five broad coding categories, including bronchitis, sinusitis, sore throat excluding strep, influenza and tonsillitis excluding strep.

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BACKGROUND: Adverse medical events affect 10% of American households annually, inducing a variety of harms and attitudinal changes. The impact of adverse events on perceived abandonment by patients and their care partners has not been methodically assessed. OBJECTIVE: To identify ways in which providers, patients and families responded to medical mishaps, linking these qualitatively and statistically to reported feelings of abandonment and sequelae induced by perceived abandonment. METHODS: Mixed-methods analysis of responses to the Massachusetts Medical Errors Recontact survey with participants reporting a medical error within the past 5 years. The survey consisted of forty closed and open-ended questions examining adverse medical events and their consequences. Respondents were asked whether they felt 'that the doctors abandoned or betrayed you or your family'. Open-ended responses were analysed with a coding schema by two clinician coders. RESULTS: Of the 253 respondents, 34.5% initially and 20% persistently experienced abandonment. Perceived abandonment could be traced to interactions before (18%), during (34%) and after (45%) the medical mishap. Comprehensive post-incident communication reduced abandonment for patients staying with the provider associated with the mishap. However, 68.4% of patients perceiving abandonment left their original provider; for them, post-error communication did not increase the probability of resolution. Abandonment accounted for half the post-event loss of trust in clinicians. LIMITATIONS: Survey-based data may under-report the impact of perceived errors on vulnerable populations. Moreover, patients may not be cognizant of all forms of adverse events or all sequelae to those events. Our data were drawn from a single state and time period. CONCLUSION: Addressing the deleterious impact of persisting abandonment merits attention in programmes responding to patient safety concerns. Enhancing patient engagement in the aftermath of an adverse medical event has the potential to reinforce therapeutic alliances between patients and their subsequent clinicians.

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OBJECTIVE: The early identification and diagnosis of transplant-associated thrombotic microangiopathy (TA-TMA) are essential yet difficult in patients underwent hematopoietic stem cell transplantation (HSCT). To develop an evidence-based, nurse-leading early warning model for TA-TMA, and implement the healthcare quality review and improvement project. METHODS: This study was a mixed-methods, before-and-after study. The early warning model was developed based on quality evidence from literature search. The healthcare quality review and improvement project mainly included baseline investigation of nurse, improvement action and effectiveness evaluation. The awareness and knowledge of early parameter of TA-TMA among nurses and the prognosis of patients underwent HSCT were compared before and after the improvement. RESULTS: A total of 1 guideline, 1 evidence synthesis, 4 expert consensuses, 10 literature reviews, 2 diagnostic studies, and 9 case series were included in the best evidence. The early warning model including warning period, high-risk characteristics and early manifestation of TA-TMA was developed. The improvement action, including staff training and assessment, suspected TA-TMA identification and patient education, was implemented. The awareness and knowledge rate of early parameter of TA-TMA among nurses significantly improved after improvement action (100% vs. 26.7%, P < 0.001). The incidence of TA-TMA was similar among patients underwent HSCT before and after improvement action (2.8% vs. 1.2%, P = 0.643), while no fall event occurred after improvement action (0 vs. 1.2%, P < 0.001). CONCLUSION: The evidence-based early warning model and healthcare quality improvement project could enhance the awareness and knowledge of TA-TMA among healthcare providers and might improve the prognosis of patients diagnosed with TA-TMA.

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INTRODUCTION: 'Hybrid' interventions in which some intervention components are fixed across sites and others are flexible (locally created) are thought to allow for adaptation to the local context while maintaining fidelity. However, there is little evidence regarding the challenges and facilitators of implementing hybrid interventions. This paper reports on a process evaluation of a patient safety hybrid intervention called Your Care Needs You (YCNY). YCNY was tested in the Partners at Care Transitions (PACT) randomised controlled trial and aimed to enhance older patients and their families' involvement in their care in order to achieve safer transitions from hospital to home. METHODS: The process evaluation took place across eight intervention wards taking part in the PACT trial. 23 interviews and 37 informal conversations were conducted with National Health Service (NHS) staff. Patients (n=19) were interviewed twice, once in hospital and once after discharge. Interviews with staff and patients concerned the delivery and experiences of YCNY. Ethnographic observations (n=81 hours) of relevant activities (eg, multidisciplinary team meetings, handovers, etc) were undertaken. RESULTS: The main finding relates to how staff understood and engaged with YCNY, which then had a major influence on its implementation. While staff broadly valued the aims of YCNY, staff from seven out of the eight wards taking part in the process evaluation enacted YCNY in a mostly task-based manner. YCNY implementation often became a hurried activity which concentrated on delivering fixed intervention components rather than a catalyst for culture change around patient involvement. Factors such as understaffing, constraints on staff time and the COVID-19 pandemic contributed towards a 'taskification' of intervention delivery, which meant staff often did not have capacity to creatively devise flexible intervention components. However, one ward with a sense of distributed ownership of YCNY had considerable success implementing flexible components. DISCUSSION: Hybrid interventions may allow aspects of an intervention to be adapted to the local context. However, the current constrained and pressured environment of the NHS left staff with little ability to creatively engage with devising flexible intervention components, despite recognising the need for and being motivated to deliver the intervention.

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BACKGROUND: The number of quality indicators for which clinicians need to record data is increasing. For many indicators, there are concerns about their efficacy. This study aimed to determine whether working with only a consensus-based core set of quality indicators in the intensive care unit (ICU) reduces the time spent on documenting performance data and administrative burden of ICU professionals, and if this is associated with more joy in work without impacting the quality of ICU care. METHODS: Between May 2021 and June 2023, ICU clinicians of seven hospitals in the Netherlands were instructed to only document data for a core set of quality indicators. Time spent on documentation, administrative burden and joy in work were collected at three time points with validated questionnaires. Longitudinal data on standardised mortality rates (SMR) and ICU readmission rates were gathered from the Dutch National Intensive Care registry. Longitudinal effects and differences in outcomes between ICUs and between nurses and physicians were statistically tested. RESULTS: A total of 390 (60%), 291 (47%) and 236 (40%) questionnaires returned at T0, T1 and T2. At T2, the overall median time spent on documentation per day was halved by 30 min (p<0.01) and respondents reported fewer unnecessary and unreasonable administrative tasks (p<0.01). Almost one-third still experienced unnecessary administrative tasks. No significant changes over time were found in joy in work, SMR and ICU readmission. CONCLUSIONS: Implementing a core set of quality indicators reduces the time ICU clinicians spend on documentation and administrative burden without negatively affecting SMR or ICU readmission rates. Time savings can be invested in patient care and improving joy in work in the ICU.

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OBJECTIVES: To assess whether conditional bedside alarm triggers can reduce the frequency of non-actionable alarms without compromising patient safety and enhance nursing and family satisfaction. STUDY DESIGN: Single center, quality improvement initiative in an acute care cardiac unit (ACCU) and pediatric intensive care unit (PICU). Following the 4-week pre-intervention baseline period, bedside monitors were programmed with hierarchical time delay and conditional alarm triggers. Bedside alarms were tallied for 4 weeks each in the immediate post intervention period and 2-year follow-up. The primary outcome was alarms per monitored patient day. Nurses and families were surveyed pre- and post-intervention. RESULTS: A total of 1509 patients contributed to 2034, 1968, and 2043 monitored patient days which were evaluated in the baseline, follow-up, and 2-year follow-up periods, respectively. The median number of alarms per monitored patient day decreased by 75% in the PICU (p<0.001) and 82% in the ACCU (p<0.001) with sustained effect at 2-year follow-up. No increase of rapid response calls, emergent transfers, or code events occurred in either unit. Nursing surveys reported an improved capacity to respond to alarms and fewer perceived non-actionable alarms. Family surveys, however, did not demonstrate improved sleep quality. CONCLUSIONS: Implemented changes to bedside monitor alarms decreased total alarm frequency in both the acute care cardiac unit and pediatric intensive care unit, improving the care provider experience without compromising safety.

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Achieving optimal patient safety (PS) remains a challenge in healthcare. Effective educational methods are critical for improving PS. Innovative teaching tools, like case-based learning, augmented reality, and active learning, can help students better understand and apply PS and healthcare quality improvement (HQI) principles. This study aimed to assess activities and tools implemented to improve PS and HQI education, as well as student engagement, in medical schools. We designed a two-week course for fourth-year medical students at the Autonomous University of Guadalajara, incorporating Fink's taxonomy of significant learning to create engaging activities. The course featured daily synchronous and asynchronous learning, with reinforcement activities using tools, like augmented reality and artificial intelligence. A total of 394 students participated, with their performance in activities and final exam outcomes analyzed using non-parametric tests. Students who passed the final exam scored higher in activities focused on application and reasoning (p = 0.02 and p = 0.018, respectively). Activity 7B, involving problem-solving and decision-making, was perceived as the most impactful. Activity 8A, a case-based learning exercise on incident reporting, received the highest score for perception of exam preparation. This study demonstrates innovative teaching methods and technology to enhance student understanding of PS and HQI, contributing to improved care quality and patient safety. Further research on the long-term impact is needed.

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BACKGROUND AND OBJECTIVES: METHODS: A structured search strategy encompassing databases including MEDLINE, Embase, CINAHL Plus, PsycINFO and Cochrane Library was implemented from inception to October 2023. Included studies focused on interventions targeting opioid reduction in adults following major surgeries. The risk of bias was evaluated using Cochrane risk-of-bias tool V.2 (RoB 2) and non-randomised studies of interventions (ROBINS-I) tools, and Cohen's d effect sizes were calculated. BCTs were identified using a validated taxonomy. RESULTS: 22 studies, comprising 7 clinical trials and 15 cohort studies, were included, with varying risks of bias. Educational (n=12), guideline-focused (n=3), multifaceted (n=5) and pharmacist-led (n=2) interventions demonstrated diverse effect sizes (small-medium n=10, large n=12). A total of 23 unique BCTs were identified across studies, occurring 140 times. No significant association was observed between the number of BCTs and effect size, and interventions with large effect sizes predominantly targeted healthcare professionals. Key BCTs in interventions with the largest effect sizes included behaviour instructions, behaviour substitution, goal setting (outcome), social support (practical), social support (unspecified), pharmacological support, prompts/cues, feedback on behaviour, environmental modification, graded tasks, outcome goal review, health consequences information, action planning, social comparison, credible source, outcome feedback and social reward. CONCLUSIONS: Understanding the dominant BCTs in highly effective interventions provides valuable insights for future opioid tapering strategy implementations. Further research and validation are necessary to establish associations between BCTs and effectiveness, considering additional influencing factors. PROSPERO REGISTRATION NUMBER: CRD42022290060.

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INTRODUCTION: Mental health disorders, particularly depression and anxiety, are widespread globally and necessitate effective solutions. The patient-centred approach has been identified as a viable and effective method for addressing these challenges. This paper synthesised the principles of patient-centred mental health services and provides a comprehensive review of the existing literature. MATERIALS AND METHODS: This is a qualitative content analysis study conducted in a systematic review framework in 2022. PubMed, Scopus, ProQuest and Cochrane databases were systematically searched, and by screening the titles, abstracts, and the texts of studies related to the purpose of the research, the data were extracted. Evaluation of the quality of the studies was done using the CASP checklist for qualitative studies. After selecting the final studies based on the entry and exit criteria, subsequently, a thematic analysis of findings was conducted on the data obtained from the systematic review. RESULTS: The database search produced 6649 references. After screening, 11 studies met the inclusion criteria. The quality scores indicated the studies were of high level of quality with acceptable risk of bias. The thematic analysis identified six major principles of patient-centredness in mental health services: education, involvement and cooperation, access, effectiveness and safety, health and well-being, and ethics. CONCLUSIONS: Patient-centredness is a complex approach in mental health services. The principles and elements of patient-centredness foster positive patient outcomes, enhance healthcare quality and ensure compassionate and effective care. Upholding these principles is crucial for delivering patient-centred, ethical and effective mental health services. Furthermore, the study found that patient education can boost adherence and satisfaction, and decrease unnecessary hospitalisations. Patient involvement in decision-making is influenced by their age and the relationship with their psychologists. And, effective leadership and resource management can enhance clinical processes and patient-centredness in mental health services.

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BACKGROUND: Workplace violence (WPV) is a complex global challenge in healthcare that can only be addressed through a quality improvement initiative composed of a complex intervention. However, multiple WPV-specific quality indicators are required to effectively monitor WPV and demonstrate an intervention's impact. This study aims to determine a set of quality indicators capable of effectively monitoring WPV in healthcare. METHODS: This study used a modified Delphi process to systematically arrive at an expert consensus on relevant WPV quality indicators at a large, multisite academic health science centre in Toronto, Canada. The expert panel consisted of 30 stakeholders from the University Health Network (UHN) and its affiliates. Relevant literature-based quality indicators which had been identified through a rapid review were categorised according to the Donabedian model and presented to experts for two consecutive Delphi rounds. RESULTS: 87 distinct quality indicators identified through the rapid review process were assessed by our expert panel. The surveys received an average response rate of 83.1% in the first round and 96.7% in the second round. From the initial set of 87 quality indicators, our expert panel arrived at a consensus on 17 indicators including 7 structure, 6 process and 4 outcome indicators. A WPV dashboard was created to provide real-time data on each of these indicators. CONCLUSIONS: Using a modified Delphi methodology, a set of quality indicators validated by expert opinion was identified measuring WPV specific to UHN. The indicators identified in this study were found to be operationalisable at UHN and will provide longitudinal quality monitoring. They will inform data visualisation and dissemination tools which will impact organisational decision-making in real time.

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BACKGROUND: Polypharmacy is frequently used as a quality indicator for older adults in Residential Aged Care Facilities (RACFs) and is measured using a range of definitions. The impact of data source choice on polypharmacy rates and the implications for monitoring and benchmarking remain unclear. We aimed to determine polypharmacy rates (≥9 concurrent medicines) by using prescribed and administered data under various scenarios, leveraging electronic data from 30 RACFs. METHOD: A longitudinal cohort study of 5662 residents in New South Wales, Australia. Both prescribed and administered polypharmacy rates were calculated biweekly from January 2019 to September 2022, providing 156 assessment times. 12 different polypharmacy rates were computed separately using prescribing and administration data and incorporating different combinations of items: medicines and non-medicinal products, any medicines and regular medicines across four scenarios: no, 1-week, 2-week and 4-week look-back periods. Generalised estimating equation models were employed to identify predictors of discrepancies between prescribed and administered polypharmacy. RESULTS: Polypharmacy rates among residents ranged from 33.9% using data on administered regular medicines with no look-back period to 63.5% using prescribed medicines and non-medicinal products with a 4-week look-back period. At each assessment time, the differences between prescribed and administered polypharmacy rates were consistently more than 10.0%, 4.5%, 3.5% and 3.0%, respectively, with no, 1-week, 2-week and 4-week look-back periods. Diabetic residents faced over two times the likelihood of polypharmacy discrepancies compared with counterparts, while dementia residents consistently showed reduced likelihood across all analyses. CONCLUSION: We found notable discrepancies between polypharmacy rates for prescribed and administered medicines. We recommend a review of the guidance for calculating and interpreting polypharmacy for national quality indicator programmes to ensure consistent measurement and meaningful reporting.

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BACKGROUND: To ensure a safe patient discharge from hospital it is necessary to transfer all relevant information in a discharge summary (DS). The aim of this study was to evaluate a bundle of measures to improve the DS for physicians, nurses and patients. METHODS: In a double-blind, randomized, controlled trial, four different versions of DS (2 original, 2 revised) were tested with physicians, nurses and patients. We used an evaluation sheet (Case report form, CRF) with a 6-point Likert scale (1 = completely agree; 6 = strongly disagree). RESULTS: In total, 441 participants (physicians n = 146, nurses n = 140, patients n = 155) were included in the study. Overall, the two revised DS received significant better ratings than the original DS (original 2.8 ± 0.8 vs. revised 2.1 ± 0.9, p < 0.001). Detailed results for the main domains are structured DS (original 1.9 ± 0.9 vs. revised 2.2 ± 1.3, p = 0.015), content (original 2.7 ± 0.9 vs revised 2.0 ± 0.9, p < 0.001) and comprehensibility (original 3.8 ± 1.2vs. revised 2.3 ± 1.2, p < 0.001). CONCLUSION: With simple measures like avoiding abbreviations and describing indications or therapies with fixed contents, the DS can be significantly improved for physicians, nurses and patients at the same time. TRIAL REGISTRATION: First registration 13/11/2020 NCT04628728 at www. CLINICALTRIALS: gov , Update 15/03/2023.

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BACKGROUND: Identifying the challenges of implementing clinical practice guidelines (CPGs) can provide valuable information for decision-makers and health policymakers at the national and local levels. The implementation of CPGs requires the development of strategies to facilitate their use. This research aimed to determine the challenges, barriers and solutions for implementing CPGs from the expert point of view in Bushehr University of Medical Sciences. METHODS: This qualitative research uses content analysis conducted in 2022 in southern Iran. In-depth interviews were conducted with the physicians and experts in the health system. Interviewing continued until reaching the saturation level. Altogether, 22 experts were interviewed. The interview guide was used to explore experts' opinions. All the interviews were recorded and then transcribed. Finally, coding and data analysis was done using MAXQDA 2022 software. RESULTS: The analysis revealed 4 main themes and 20 subthemes. The four main themes included challenges related to physicians, medical education, the health system and patients. The most common themes were the lack of sufficient training (related to the medical education system), equipment and infrastructure, and the lack of adaptation of clinical guidelines (related to the health system). The solutions included 4 main themes and 19 subthemes. CONCLUSION: The most mentioned topic by the experts was training CPGs in medical schools. In Iran's current medical education system, the training of CPGs is not included in the curriculum. It is proposed to reform the medical education system in Iran. In addition, health inequalities such as lack of access to equipment, supplies and insurance in under-resourced areas and disparities in research/training/medical education should be addressed to improve the validity of guidelines.

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BACKGROUND: Early intervention for unmet needs is essential to improve health. Clear inequalities in healthcare use and outcomes exist. The Children and Young People's Health Partnership (CYPHP) model of care uses population health management methods to (1) identify and proactively reach children with asthma, eczema and constipation (tracer conditions); (2) engage these families, with CYPHP, by sending invitations to complete an online biopsychosocial Healthcheck Questionnaire; and (3) offer early intervention care to those children found to have unmet health needs. We aimed to understand this model's effectiveness to improve equitable access to care. METHODS: We used primary care and CYPHP service-linked records and applied the same methods as the CYPHP's population health management process to identify children aged <16 years with a tracer condition between 1 April 2018 and 30 August 2020, those who engaged by completing a Healthcheck and those who received early intervention care. We applied multiple imputation with multilevel logistic regression, clustered by general practitioner (GP) practice, to investigate the association of deprivation and ethnicity, with children's engagement and receiving care. RESULTS: Among 129 412 children, registered with 70 GP practices, 15% (19 773) had a tracer condition and 24% (4719) engaged with CYPHP's population health management system. Children in the most deprived, compared with least deprived communities, had 26% lower odds of engagement (OR 0.74; 95% CI 0.62 to 0.87). Children of Asian or black ethnicity had 31% lower odds of engaging, compared with white children (0.69 (0.59 to 0.81) and 0.69 (0.62 to 0.76), respectively). However, once engaged with the population health management system, black children had 43% higher odds of receiving care, compared with white children (1.43 (1.15 to 1.78)), and children from the most compared with least deprived communities had 50% higher odds of receiving care (1.50 (1.01 to 2.22)). CONCLUSION: Detection of unmet needs is possible using population health management methods and increases access to care for children from priority populations with the highest needs. Further health system strengthening is needed to improve engagement and enhance proportionate universalist access to healthcare. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03461848).