BACKGROUND:Improving paediatric diagnosis by addressing errors (Safety-I) is insufficient for diagnostic excellence. Resilience engineering's approach to understanding adaptations to achieve success in everyday work may elucidate how individuals and systems manage diagnostic complexity to achieve diagnostic success (Safety-II). Our objective was to characterise resilience-promoting behaviours of patients/families and clinicians and resilient organisational properties in outpatient diagnosis of children with medical complexity. METHODS:This ethnographic study included observations of outpatient visits and semistructured interviews of parents/guardians and providers. Resilience engineering frameworks informed data collection and analysis. We prospectively sampled patients <18 years old with medical complexity presenting with acute problems in clinics at three academic health systems from 25 January 2024 to 26 February 2025. We qualitatively coded field notes and interview transcripts, focusing on individual resilient behaviours and instances of organisational resilience. We identified resilience themes using directed content analysis and described the frequency and types of resilience concepts. RESULTS:We observed 258 unique resilience-promoting behaviours and organisational properties in 31 of 33 (94%) patient visits, with an average of 7.8 resilient behaviours/properties per visit. Of these, 178 (69%) reflected patient/family and clinician activities to promote diagnostic resilience and 80 (31%) reflected organisational resilience relevant to diagnosis. The most frequently identified resilience behaviours/properties were anticipation (prediction of future events and contingency planning), monitoring (vigilant observation for clinical evolution), robustness (comprehensiveness and redundancy in the diagnostic process) and graceful extensibility (stretching resources to meet diagnostic needs). CONCLUSIONS:Resilient behaviours by patients/families and clinicians and resilient organisational properties supporting diagnostic excellence can be prevalent in outpatient paediatrics for children with medical complexity. Future research should characterise diagnostic resilience's impact on diagnostic safety and patient/family outcomes.
BACKGROUND:Knowledge brokers act as intermediaries to bridge evidence-to-practice gaps. Limited evidence describes how the knowledge broker role in health settings evolves over time. This study aimed to (a) examine the evolution of knowledge broker activities over a 12-month implementation trial and (b) identify enablers necessary to strengthen and support the role. METHODS:This longitudinal multi-method study is nested within the 12-month Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE) trial. The EMBRACE intervention involved knowledge brokers working in 19 residential aged care facilities (RACFs) to support implementation of Australia's Clinical Practice Guidelines for the Appropriate Use of Psychotropic Medications in People Living with Dementia in Residential Aged Care. Seventy-six knowledge broker local action plans, representing 19 RACFs at four time points, were analysed to characterise core knowledge broker functions and the frequency of planned quality improvement activities targeting seven pre-defined sub-indicators of psychotropic appropriateness. The Consolidated Framework for Implementation Research informed thematic analysis of 76 separate quarterly written reflections and 28 semistructured interviews with knowledge brokers. RESULTS:The number and breadth of knowledge broker activities increased over time. At baseline, six RACF local action plans included activities targeted towards at least one sub-indicator, increasing to all 19 local action plans from the 3-month timepoint onwards. Knowledge brokers enacted overlapping functions as knowledge managers, linkage agents and capacity builders, although the timing and extent of role progression varied across RACFs and individuals. Evolution of activities was shaped by individual (clinical leaders, implementation facilitators, peer support) organisational (culture, governance pathways, digital integration) and outer setting factors (COVID-19 disruptions, national policy directives). CONCLUSION:The knowledge broker role fundamentally evolved from assessing local context and establishing foundational rapport to driving systemic change. Effective translation of guidelines into practice requires future implementation programmes to support this role with a strong organisational culture, robust infrastructure and strategic alignment with RACFs and national priorities.
BACKGROUND:Sepsis and infection are distinct yet overlapping conditions in the intensive care unit (ICU), posing diagnostic and management challenges due to non-specific clinical features and delayed microbiological confirmation. This study aimed to develop and evaluate a real-time dual-model clinical decision support system for early identification of infection and sepsis based on the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) framework. METHODS:We conducted a retrospective model development and prospective non-interventional deployment study of adult ICU admissions between 2018 and 2020 at a tertiary-care medical centre. Infection was defined by positive microbiological culture results while sepsis was defined according to Sepsis-3 criteria. Two machine learning models were developed using structured clinical features from an 8-hour feature window to predict infection and sepsis. The framework included an 8-hour lead time and a 1-hour prediction window. Class imbalance was addressed using propensity score matching and Borderline Synthetic Minority Oversampling Technique. External validation was performed using the Medical Information Mart for Intensive Care IV database. Real-time deployment analyses evaluated ICU risk surveillance and cluster-based stratification using combined sepsis and infection probabilities. RESULTS:The dual-model system demonstrated consistent discrimination across internal, reduced-feature and external validation cohorts, with area under the receiver operating characteristic curves ranging from 0.75 to 0.85. Both models prioritised high sensitivity and negative predictive value to minimise missed cases. During real-time ICU implementation, the decision support dashboard provided interpretable risk estimates at the bedside. Exploratory pre-post comparisons showed numerically lower point estimates across most clinical and resource-utilisation outcomes, without adjustment for confounding factors. Cluster-based analysis further identified a high-risk subgroup with greater healthcare resource utilisation. CONCLUSION:This real-time clinical decision support system enables early identification of infection and sepsis, supports timely clinical decision-making and may inform antibiotic and resource use in the ICU.
IMPORTANCE:Patient safety and systems integration (PSSI) simulations help uncover hazards that jeopardise patient safety. Using direct observation, video analysis and systems-focused debriefing, they identify and categorise latent safety threats (LSTs). We aimed to compare the number, nature and potential risk of LSTs across the three modalities. METHODS:In a prospective observational cohort, six unannounced simulations were conducted in a paediatric emergency department during active shifts. Two raters independently identified LSTs, which were coded deductively using the adapted Systems Engineering Initiative for Patient Safety (SEIPS) framework and inductively for emergent themes. Harm potential was graded using Healthcare Failure Mode and Effect Analysis (HFMEA). LSTs were mapped onto a framework matrix for comparison within and across detection modalities. The primary outcome was differences in LSTs detected by each modality; number, nature (SEIPS) and proportion of critical threats (HFMEA score ≥8). RESULTS:Seventy-two providers participated (mean 12.0±2.3/simulation). 2576 unique LSTs were identified. Video detected the most LSTs (n=1908), compared with observation (n=426) or debriefing (n=242, p<0.01). Although fewer overall, debriefing yielded the highest proportion of critical threats (54.9% (124/226), p<0.01) compared with observation (26.3% (109/414)) or video (23.6% (442/1875)). Debriefing often revealed task-specific and communication-related threats, whereas video excelled at physical workspace and infection control deficits. Inter-rater reliability for SEIPS coding was acceptable (κ≥0.7). CONCLUSION:Although debriefing yielded fewer LSTs, it is valuable for surfacing critical LSTs (54.9% vs 23.6% video). We highlight the strengths of LST detection modalities and provide insights for institutions selecting strategies to mitigate harm and enhance system resilience.
IMPORTANCE:Quality improvement efforts on general medical wards are often driven by organisational or clinician priorities, and little is known about patient or caregiver priorities. OBJECTIVE:To understand contributors to patients' in-hospital experience and how patients and caregivers prioritise these for improvement. METHODS:We recruited inpatients or their caregivers from the general medical wards of 10 hospitals across Canada from November 2023 to February 2025 to participate in a group concept mapping study. Group concept mapping is a participatory multistep mixed method used to understand how a group views a particular topic. We used a targeted recruitment strategy to ensure inclusion of individuals who identified as non-white, preferred a non-English language, were unhoused, had a history of a mental health condition or who had dementia. An open-ended prompt elicited narratives about the inpatient experience. These were iteratively summarised into statements, which subsequent participants thematically sorted and rated in response to two rating questions: (1) extent of negative impact on well-being and (2) prioritisation for quality improvement. RESULTS:302 participants (230 patients, 72 caregivers) responded to the open-ended prompt. These were synthesised into 935 ideas, summarised into 42 unique statements, which were then rated (N=203 participants) and sorted (N=50), generating a concept map with six clusters: Environment & Facilities, Personal Support, Delays, Communication, Nutrition, Inclusivity & Engagement. There was no correlation between rating results for impact to well-being versus prioritisation for quality improvement. The 'Delays', 'Communication' and 'Inclusivity & Engagement' conceptual clusters contained many of the highest-rated improvement priorities. Prioritisation was consistent across participant subgroups, despite variation in how these groups rated items on impact to well-being. CONCLUSION:This study provides a ranked list of priorities, setting an agenda that is grounded in the patient experience. Overall, patients' and caregivers' own negative inpatient experiences had little bearing on overall prioritisation for quality improvement.
BACKGROUND:Clinician burnout is prevalent and associated with poorer patient safety outcomes. Although mindfulness-based interventions can improve clinician resilience, most are time-intensive and not easily embedded into clinical workflows. We thus evaluated a brief mindfulness-based intervention designed to enhance mindful awareness and clinician well-being among physicians and nurses. SETTING:Two Veterans Affairs academic medical centres in (Ann Arbor, MI, USA) and (Houston, TX, USA). DESIGN:A randomised controlled, mixed methods study was conducted. Physicians and nurses were randomised to intervention or control at the team/unit level. Quantitative data were collected at baseline, 1 month and 7 months; qualitative interviews and group discussions explored acceptability and perceived impact. PARTICIPANTS:A total of 456 clinicians were randomised and 343 consented to participate (170 intervention and 173 control). Participants included attending and resident physicians and registered nurses working on inpatient general medicine wards. INTERVENTION:The intervention integrated mindfulness practice into routine hand hygiene moments. Components included self-directed online training and a brief facilitated group discussion led by site mindfulness champions. Control participants received no intervention. MAIN OUTCOME MEASURES:Primary outcomes were self-reported mindfulness (Five Facet Mindfulness Questionnaire (FFMQ)-possible range 1-5, higher scores better) and well-being (Well-Being Index (WBI)-possible range -2 to 9, lower scores better). RESULTS:Clinicians highly engaged (completed modules and discussion) with the intervention showed significant increases in mindfulness (FFMQ) at 1 month (β=0.23; p< 0.001) and 7 months (β=0.23; p<0.001) versus controls. Well-being (WBI) improved modestly over time, with non-significant trends towards reduced distress in the intervention group. One hundred forty-eight clinicians participated in a group discussion and 16 in a semistructured interview. Qualitative findings indicated high acceptability and perceived benefits, including enhanced focus and calm, but identified time pressures and cultural barriers to sustained practice. CONCLUSIONS:Embedding mindfulness into routine behaviours such as hand hygiene is feasible and improved clinicians' mindful awareness, although it did not significantly improve well-being. Microinterventions that integrate mindfulness into clinical workflows may offer scalable approaches to support clinician presence, focus and mental resilience. TRIAL REGISTRATION NUMBER:NCT05261282.
BACKGROUND:Emergency policies designed to protect populations can inadvertently cause diagnostic harm when essential services are suspended. How such policies reshape gender gaps in cancer detection, and whether either sex faces disproportionate harm, remains underexplored. OBJECTIVES:We leveraged Taiwan's 2021 level 3 alert-a precautionary directive implemented during minimal COVID-19 transmission (0.07%) that mandated hospital capacity reductions and school closures-as a natural experiment to test whether the alert produced gendered diagnostic disruptions. METHODS:Using Taiwan Cancer Registry and National Health Insurance claims (N=312 522; 2015-2021), we employed interrupted time series and difference-in-differences models to estimate changes in cancer detection rates and tumour size at diagnosis; robustness was confirmed through sensitivity and falsification tests. RESULTS:The alert disproportionately reduced detection of early-stage cancers, consistent with a collapse of preventive and opportunistic detection pathways. Women experienced larger declines in detection than men (-43.9% vs -32.0%; p=0.001) and greater increases in tumour size (17.3% vs 11.5%; p=0.026). These gaps were most pronounced among women under 50 (-50.7% vs -25.5%; p=0.001) and disadvantaged women, whose tumour size increase was nearly double that of disadvantaged men (16.6% vs 8.8%; p=0.049). The gap was particularly large for opportunistically detected cancers (lung: -47.1% women vs -22.6% men; p=0.011). CONCLUSIONS:These findings reveal a system-level patient safety failure. Women's higher engagement with routine care, ordinarily a health advantage, became a structural vulnerability when these pathways were suspended, possibly amplified by intensified caregiving, employment shocks and infection-risk avoidance. As health systems prepare for recurring shocks, resilience planning must incorporate gender-sensitive safeguards that prevent diagnostic harm. Protecting early detection pathways is both a clinical imperative and a patient safety requirement for equitable emergency response.
Background Efforts to improve diagnosis should reflect the unique needs of children; however, there is no consensus on paediatric-specific priority areas. Methods An expert panel of 25 United States (US) paediatric diagnostic excellence researchers, patient safety leaders and family partners from 15 institutions participated in a modified Delphi panel. Panellists participated in generating a literature-derived list of topics relevant to improving diagnosis. Panellists then rated agreement on each topic as a research or operational improvement priority. Topics that achieved consensus (≥75% of panellists rating them as high priority) were subsequently rated based on feasibility for implementation at the respondent’s institution. Results Literature review identified 24 topics relevant to paediatric diagnostic safety and quality, which were expanded to 62 topics during the initial panel discussion and grouped into 25 survey topics. Consensus was reached on 6 topics as research priorities and 11 as operational improvement priorities. Of these, three were deemed highly feasible for research and three for operational improvement. Research priorities included: identifying paediatric conditions at high risk for diagnostic error, developing communication methods to enhance the diagnostic process and establishing diagnostic process feedback mechanisms. Operational improvement priorities included: identifying care delivery or health services scenarios at high risk for diagnostic error, establishing interdisciplinary, structured review of cases of diagnostic error and encouraging reporting of missed opportunities for improving diagnostic safety. Conclusion Experts successfully prioritised important and feasible topics in research and practice for improving paediatric diagnosis in US academic medical centres.
BACKGROUND:Improvement science has supported the methodological foundations for the application of quality improvement (QI) in healthcare. However, concerns persist regarding the rigour of QI evaluation. Theories, Models and Frameworks (TMFs) from implementation science support the uptake of evidence-based practices but their use to guide the evaluation of QI initiatives remains insufficiently characterised. OBJECTIVES:To identify which implementation science TMFs have been used to evaluate QI initiatives in healthcare, assess how these TMFs were applied in the evaluation, and compare the TMFs' intrinsic methodological attributes. METHODS:We conducted a scoping review following Arksey and O'Malley's framework. Eligible studies were published between 2010 and 2025 and evaluated a QI initiative using at least one TMF. Peer-reviewed literature was searched in PubMed, Scopus and Web of Science. Grey literature was retrieved through targeted Google searches. TMFs were evaluated at the article level according to their application in each study and at the TMF level according to their intrinsic methodological attributes. RESULTS:Out of 1824 records screened, 80 studies were included. 23 unique TMFs were identified. Of these, the most frequently used were the Reach, Effectiveness, Adoption, Implementation and Maintenance framework (27%) and the Consolidated Framework for Implementation Research (20%). Although 94% of studies used TMFs to guide data collection or analysis, only 43% explicitly tested construct relationships or causal pathways. TMFs demonstrated high conceptual clarity and structure but limited equity and sociocultural responsiveness. CONCLUSIONS:Application of TMFs in the evaluation of QI initiatives was heterogeneous. No single TMF captured the full range of evaluative functions. More rigorous evaluation requires an integrative approach that combines complementary TMFs to examine context, mechanisms of improvement and outcomes. Prospective operationalisation of TMF constructs, particularly equity, within study design and evaluation is essential to strengthen reproducibility and improve the transferability of findings across settings.
Remote consulting was rapidly implemented in UK general practice with limited preparation or training. Subsequent research and national investigations have identified patient safety risks. Although evidence-based recommendations and competencies for safer remote care now exist, there is limited guidance on how to implement them in everyday practice.This project aimed to develop, pilot and refine a scalable, whole-team training intervention and to assess its feasibility and acceptability within general practice.Drawing on findings from the Remote by Default 2 study and national patient safety investigations, we co-produced a vignette-based, whole-practice training package with NHS (National Health Service) Resolution and the Health Services Safety Investigations Body. Seven fictionalised patient safety cases were developed to reflect common risks in remote care and were designed to be worked through by practice teams using their own systems and processes. Training was delivered to six general practices across the UK in facilitated sessions lasting 1-2 hours. Anonymous staff feedback was collected immediately after training, with additional reflective feedback obtained several weeks later to support iterative refinement.Sixty-seven staff participated, including clinicians, managers, receptionists and administrative staff. Feedback suggested that the case-based format was engaging and supported whole-team reflection on how remote care systems operate in practice. Participants valued the focus on practice systems rather than individual performance and reported perceived increased awareness of safety risks associated with remote consulting. Equity-related issues featured prominently, with teams reflecting on how remote access and triage processes may disadvantage some patient groups and identifying potential system changes, such as prioritising face-to-face assessment or updating vulnerability registers.This study has demonstrated the feasibility and acceptability of whole-team, systems-focused training to support safer remote general practice.
BACKGROUND:Low-value practices, defined as tests or treatments that are used in practice despite not being supported by evidence, account for 20%-30% of healthcare expenditure; moreover, some identified low-value practices represent 16%-26% of primary care clinical services. Given the growing financial constraints healthcare systems face, evaluating the cost-effectiveness of interventions designed to reduce these practices is becoming urgent. OBJECTIVE:We aimed to synthesise data on the economic value of deimplementation interventions. METHODS:We evaluated the cost-effectiveness of interventions targeting the deimplementation of low-value practices among healthcare professionals and organisations (clinicians, hospitals and medical centres). Our comparator was either no intervention or a deimplementation intervention limited to a subset of the intervention components. Outcomes were incremental cost-effectiveness ratios, incremental cost-utility ratios and benefit-to-cost ratios. Studies where the intervention was dominant or dominated by the comparator were also considered. We developed search strategies for Cochrane, EMBASE, MEDLINE, CINAHL and Web of Science to February 2025. Pairs of independent reviewers sequentially screened titles, abstracts and full texts for eligibility and extracted data using a prepiloted extraction sheet. Methodological quality was assessed by two reviewers using the 19-item Consensus on Health Economic Criteria (CHEC), and results were synthesised visually using permutation matrices globally and for predefined subgroups. RESULTS:Of the 35 575 unique records identified, 19 met our eligibility criteria. Deimplementation interventions were found to be dominant (ie, effective with lower cost) in 10 evaluations (53%), potentially favourable (more effective with higher cost) in 8 (42%) and unfavourable in 1 (5%). Deimplementation interventions were more likely to be economically favourable in studies accounting for both medical and intervention costs, those targeting healthcare professionals and those with high methodological quality. CONCLUSION:Our findings suggest that deimplementation interventions targeting low-value practices are highly likely to be cost-effective. However, the results should be interpreted with caution due to the low methodological quality of the studies and the lack of consideration of the societal perspective.
BACKGROUND:Champions play a critical role in driving innovation, advancing evidence-based practice (EBP) and supporting its implementation across diverse healthcare settings. This paper describes the development of a Champions' Competencies Framework outlining the knowledge, skills, behaviours, attitudes, roles and responsibilities required of champions. Informed by existing literature, the framework is intended for members of the global Best Practice Champions Network (BPCN), including nurses, health and social service providers, volunteers and students. METHODS:The framework was developed in three phases. Phase I involved a grey literature scan to identify sources describing champions' competencies. Phase II followed Arksey and O'Malley's scoping review methodology. Studies published between 1 January 2010 and 28 March 2025 were identified through searches of Cochrane, CINAHL, Embase, ePub, MEDLINE and PsycINFO using Boolean operators and Medical Subject Headings (MeSH). Titles and abstracts were independently screened by two reviewers followed by a full-text review. Phase III involved thematic synthesis and consultation with external partners to refine the framework. RESULTS:63 studies met the inclusion criteria and were analysed. Seven core competency roles were identified: leader, advocate, collaborator, communicator, content and context expert, facilitator and mentor, supported by 34 performance statements. CONCLUSION:Champions are key drivers of EBP in healthcare. This framework advances understanding of champion competencies and supports skill development, while enabling organisations to design competency-based training and tailor context-specific strategies to enhance the uptake and sustainability of EBPs.
The rapid growth in quality indicators (QIs) has increased complexity in selecting those that are effective for monitoring provider quality and patient outcomes. Existing selection methodologies are often insufficiently transparent or standardised and influenced by subjective opinions. To develop an instrument for evidence-based collection and evaluation of QIs that are suitable for quality monitoring, and which can be applied to various healthcare areas (HCAs; defined by care setting). The instrument was developed with HCA-specific experts, who provided feedback on its components and piloted its use in the Swiss context. We conducted a literature search with snowballing to identify prioritisation criteria and weighted these using the Analytic Hierarchy Process (AHP). We developed a template to facilitate data collection and the QI evaluation. The final QUALICATOR instrument consists of five steps: (1) definition of search scope; (2) utilisation of 12 prioritisation criteria across four dimensions (relevance, scientific soundness, usability, feasibility); (3) application of a data collection template objectifying the prioritisation criteria; (4) preselection via knockout criteria and (5) final prioritisation via weighting multicriteria decision analysis. Final criteria weights derived via the AHP varied substantially across HCAs (eg, relevance: 19.16%-57.10%; scientific soundness: 5.50%-39.50%; usability: 13.17%-33.75%; feasibility: 11.78%-45.57%), reflecting HCA-specific priorities. A web-based prototype is available to support a user-friendly application. This QUALICATOR instrument provides a transparent, scalable approach to navigate through a growing body of QIs with further validation needed. It provides a methodological framework and proof of concept, rather than a ready-to-use solution. It shows policymakers, providers and payers a path to make informed decisions about which QIs to prioritise, monitor, invest in and act on.
