There frequently exists a gap between known best practices and real-world methods. Closing this gap involves thoughtful implementation, typically involving multiple implementation strategies. Implementation mapping is a technique that links the innovation being implemented with potential barriers to implementation and connects these barriers to the strategies that form the implementation plan. This study demonstrates the application of implementation mapping to guide the adoption of the Epic Health Systems Intraoperative Anesthesia Handoff Report. The objective is to create a comprehensive implementation plan tailored to the anticipated challenges of the local environment. There are five steps in implementation mapping: (1) performing a needs assessment, (2) creating a matrix of change, (3) identifying the mechanisms of change and strategies for change, (4) creating implementation materials, and (5) measuring implementation outcomes. Through the creation of this map, a multi-pronged implementation strategy was created and executed. This implementation plan resulted in high acceptability, appropriateness, and feasibility scores among frontline anesthesia clinicians adopting the intraoperative anesthesia tool. The logical connections between the barriers and the implementation strategies further facilitated changes to the implementation plan as new challenges arose during the implementation process. This study addresses a critical gap in clinical practice by providing a structured approach to implementing best practices in anesthesiology. Implementation mapping can potentially be a valuable technique for guiding quality improvement projects involving implementing new clinical practices in anesthesiology.

The telencephalon of the mammalian brain comprises multiple regions and circuit pathways that play adaptive and integrative roles in a variety of brain functions. There is a wide array of GABAergic neurons in the telencephalon; they play a multitude of circuit functions, and dysfunction of these neurons has been implicated in diverse brain disorders. In this study, we conducted a systematic and in-depth analysis of the transcriptomic and spatial organization of GABAergic neuronal types in all regions of the mouse telencephalon and their developmental origins. This was accomplished by utilizing 611,423 single-cell transcriptomes from the comprehensive and high-resolution transcriptomic and spatial cell type atlas for the adult whole mouse brain we have generated, supplemented with an additional single-cell RNA-sequencing dataset containing 99,438 high-quality single-cell transcriptomes collected from the pre- and postnatal developing mouse brain. We present a hierarchically organized adult telencephalic GABAergic neuronal cell type taxonomy of 7 classes, 52 subclasses, 284 supertypes, and 1,051 clusters, as well as a corresponding developmental taxonomy of 450 clusters across different ages. Detailed charting efforts reveal extraordinary complexity where relationships among cell types reflect both spatial locations and developmental origins. Transcriptomically and developmentally related cell types can often be found in distant and diverse brain regions indicating that long-distance migration and dispersion is a common characteristic of nearly all classes of telencephalic GABAergic neurons. Additionally, we find various spatial dimensions of both discrete and continuous variations among related cell types that are correlated with gene expression gradients. Lastly, we find that cortical, striatal and some pallidal GABAergic neurons undergo extensive postnatal diversification, whereas septal and most pallidal GABAergic neuronal types emerge simultaneously during the embryonic stage with limited postnatal diversification. Overall, the telencephalic GABAergic cell type taxonomy can serve as a foundational reference for molecular, structural and functional studies of cell types and circuits by the entire community.

BackgroundRegulatory quantitative assessments are routinely undertaken to understand the patient safety culture within an organization. However, adjunctive qualitative approaches to explore low-scoring areas of safety culture in the operating room (OR) are lacking and may provide additional insight. Thus, we explored OR patient safety culture perceptions of pediatric surgical providers, specifically among attending physicians and trainees.MethodsA cross-sectional survey was pilot-tested by pediatric surgical attending physicians and surgical trainees from one academic hospital OR. The “Safer Culture” survey was developed using validated survey measures of concepts from the Safer Culture framework and modified by cognitive interviews with subject-matter experts. The survey was electronically administered, and the results were analyzed descriptively, and percent positive scores were computed. Semi-structured interviews with a purposive sample of participants were then conducted and thematically analyzed.ResultsOf the 144 participants, 67 completed the survey (response rate: 46.5%). Safety competence (>95%) and individual commitment & prioritization of safety (>90%) were rated highest by attending physicians and trainees. Trainees rated policies & resources for safety and cohesion the lowest (<60%). Attending physicians and trainees rated just culture the lowest (<56%). Interview data revealed three overarching themes explain the lowest ratings: 1) feedback and fear influence incident reporting, 2) lack of accountability and learning affect just culture, and 3) individual and group preparedness impact safe surgical care.ConclusionsSafer Culture survey identified low-performing issues affecting OR safety culture by pediatric surgical providers. Their perceptions specified areas to focus initiatives to improve OR safety culture.Levels of EvidenceLevel III

The ambulatory diagnostic process is potentially complex, resulting in faulty communication, lost information, and a lack of team coordination. Patients and families have a unique position in the ambulatory diagnostic team, holding privileged information about their clinical conditions and serving as the connecting thread across multiple healthcare encounters. While experts advocate for engaging patients as diagnostic team members, operationalizing patient engagement has been challenging. The team science literature links improved team performance with shared mental models, a concept reflecting the team's commonly held knowledge about the tasks to be done and the expertise of each team member. Despite their proven potential to improve team performance and outcomes in other settings, shared mental models remain underexplored in healthcare. In this manuscript, we review the literature on shared mental models, applying that knowledge to the ambulatory diagnostic process. We consider the role of patients in the diagnostic team and adapt the five-factor model of shared mental models to develop a framework for patient-clinician diagnostic shared mental models. We conclude with research priorities. Development, maintenance, and use of shared mental models of the diagnostic process amongst patients, families, and clinicians may increase patient/family engagement, improve diagnostic team performance, and promote diagnostic safety.

Background: The emotional impact of medical errors on patients may be long-lasting. Factors associated with prolonged emotional impacts are poorly understood. Methods: The authors conducted a subanalysis of a 2017 survey (response rate 36.8% [2,536/6,891]) of US adults to assess emotional impact of medical error. Patients reporting a medical error were included if the error occurred >= 1 year prior. Duration of emotional impact was categorized into no/short-term impact (impact lasting < 1 month), prolonged impact ( > 1 month), and especially prolonged impact ( > 1 year). Based on their reported experience with communication about the error, patients' experience was categorized as consistent with national disclosure guidelines, contrary to guidelines, mixed, or neither. Multinomial regression was used to examine associations between patient factors, event characteristics, and organizational communication with prolonged emotional impact ( > 1 month, > 1 year). Results: Of all survey respondents, 17.8% (451/2,536) reported an error occurring >= 1 year prior. Of these, 51.2% (231/451) reported prolonged/especially prolonged emotional impact (30.8% prolonged, 20.4% especially prolonged). Factors associated with prolonged emotional impact included female gender (adjusted odds ratio 2.1 [95% confidence interval 1.5-2.9]); low socioeconomic status (SES; 1.7 [1.1-2.7]); physical impact (7.3 [4.3-12.3]); no organizational disclosure and no patient/family error reporting (1.5 [1.03-2.3]); communication contrary to guidelines (4.0 [2.1-7.5]); and mixed communication (2.2 [1.3-3.7]). The same factors were significantly associated with especially prolonged emotional impact (female, 1.7 [1.2-2.5]; low SES, 2.2 [1.3-3.6]; physical impact, 6.8 [3.8-12.5]; no disclosure/reporting, 1.9 [1.2-3.2]; communication contrary to guidelines, 4.6 [2.2-9.4]; mixed communication, 2.1 [1.1-3.9]). Conclusion: Prolonged emotional impact affected more than half of Americans self-reporting a medical error. Organizational failure to communicate according to disclosure guidelines after patient-perceived errors may exacerbate harm, particularly for patients at risk of health care disparities.

Dynamic teaming is required whenever people must coordinate with one another in a fluid context, particularly when the fundamental structures of a team, such as membership, priorities, tasks, modes of communication, and location are in near-constant flux. This is certainly the case in the contemporary ambulatory care diagnostic process, where circumstances and conditions require a shifting cast of individuals to coordinate dynamically to ensure patient safety. This article offers an updated perspective on dynamic teaming commonly required during the ambulatory diagnostic process. Drawing upon team science, it clarifies the characteristics of dynamic diagnostic teams, identifies common risk points in the teaming process and the practical implications of these risks, considers the role of providers and patients in averting adverse outcomes, and provides a case example of the challenges of dynamic teaming during the diagnostic process. Based on this, future research needs are offered as well as clinical practice recommendations related to team characteristics and breakdowns, team member knowledge/cognitions, teaming dynamics, and the patient as a team member.

Objectives Accurate and timely diagnosis relies on close collaboration between patients/families and clinicians. Just as patients have unique insights into diagnostic breakdowns, positive patient feedback may also generate broader perspectives on what constitutes a "good" diagnostic process (DxP).Methods We evaluated patient/family feedback on "what's going well" as part of an online pre-visit survey designed to engage patients/families in the DxP. Patients/families living with chronic conditions with visits in three urban pediatric subspecialty clinics (site 1) and one rural adult primary care clinic (site 2) were invited to complete the survey between December 2020 and March 2022. We adapted the Healthcare Complaints Analysis Tool (HCAT) to conduct a qualitative analysis on a subset of patient/family responses with >=;20 words.Results In total, 7,075 surveys were completed before 18,129 visits (39 %) at site 1, and 460 surveys were completed prior to 706 (65 %) visits at site 2. Of all participants, 1,578 volunteered positive feedback, ranging from 1-79 words. Qualitative analysis of 272 comments with >= 20 words described: Relationships (60 %), Clinical Care (36 %), and Environment (4 %). Compared to primary care, subspecialty comments showed the same overall rankings. Within Relationships, patients/families most commonly noted: thorough and competent attention (46 %), clear communication and listening (41 %) and emotional support and human connection (39 %). Within Clinical Care, patients highlighted: timeliness (31 %), effective clinical management (30 %), and coordination of care (25 %).Conclusions Patients/families valued relationships with clinicians above all else in the DxP, emphasizing the importance of supporting clinicians to nurture effective relationships and relationship-centered care in the DxP.

BackgroundAccurate and timely diagnosis relies on sharing perspectives among team members and avoiding information asymmetries. Patients/Families hold unique diagnostic process (DxP) information, including knowledge of diagnostic safety blindspots-information that patients/families know, but may be invisible to clinicians. To improve information sharing, we co-developed with patients/families an online tool called 'Our Diagnosis (OurDX)'. We aimed to characterise patient/family contributions in OurDX and how they differed between individuals with and without diagnostic concerns. MethodWe implemented OurDX in two academic organisations serving patients/families living with chronic conditions in three subspecialty clinics and one primary care clinic. Prior to each visit, patients/families were invited to contribute visit priorities, recent histories and potential diagnostic concerns. Responses were available in the electronic health record and could be incorporated by clinicians into visit notes. We randomly sampled OurDX reports with and without diagnostic concerns for chart review and used inductive and deductive qualitative analysis to assess patient/family contributions. Results7075 (39%) OurDX reports were submitted at 18 129 paediatric subspecialty clinic visits and 460 (65%) reports were submitted among 706 eligible adult primary care visits. Qualitative analysis of OurDX reports in the chart review sample (n=450) revealed that participants contributed DxP information across 10 categories, most commonly: clinical symptoms/medical history (82%), tests/referrals (54%) and diagnosis/next steps (51%). Participants with diagnostic concerns were more likely to contribute information on DxP risks including access barriers, recent visits for the same problem, problems with tests/referrals or care coordination and communication breakdowns, some of which may represent diagnostic blindspots. ConclusionPartnering with patients and families living with chronic conditions through OurDX may help clinicians gain a broader perspective of the DxP, including unique information to coproduce diagnostic safety.

Safety & Security Science, Delft University of Technology, Faculty of Technology, Policy & Management, Delft, The Netherlands Centre for Safety in Healthcare, Delft University of Technology, Delft, The Netherlands Internal Medicine, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas, USA The UTHealthMemorial Hermann Center for Healthcare Quality and Safety, UTHealth, Houston, Texas, USA Stony Brook University, Stony Brook, New York, USA

This paper reviews the current state of patient safety and the application of artificial intelligence (AI) techniques to patient safety. This paper defines patient safety broadly, not just inpatient care but across the continuum of care, including diagnostic errors, misdiagnosis, adverse events, injuries, and measurement issues. It outlines the major current uses of AI in patient safety and the relative adoption of these techniques in hospitals and health systems. It also outlines some of the limitations of these AI systems and the challenges with evaluation of these systems. Finally, it outlines the importance of developing a proactive agenda for AI in healthcare that includes marked increased funding of research and evaluation in this area.

BACKGROUND:Patients and families at risk for health disparities may also be at higher risk for diagnostic errors but less likely to report them.OBJECTIVES:This study aimed to explore differences in race, ethnicity, and language preference associated with patient and family contributions and concerns using an electronic previsit tool designed to engage patients and families in the diagnostic process (DxP).METHODS:Cross-sectional study of 5,731 patients and families presenting to three subspecialty clinics at an urban pediatric hospital May to December 2021 who completed a previsit tool, codeveloped and tested with patients and families. Prior to each visit, patients/families were invited to share visit priorities, recent histories, and potential diagnostic concerns. We used logistic regression to determine factors associated with patient-reported diagnostic concerns. We conducted chart review on a random subset of visits to review concerns and determine whether patient/family contributions were included in the visit note.RESULTS:Participants provided a similar mean number of contributions regardless of patient race, ethnicity, or language preference. Compared with patients self-identifying as White, those self-identifying as Black (odds ratio [OR]: 1.70; 95% confidence interval [CI]: [1.18, 2.43]) or "other" race (OR: 1.48; 95% CI: [1.08, 2.03]) were more likely to report a diagnostic concern. Participants who preferred a language other than English were more likely to report a diagnostic concern than English-preferring patients (OR: 2.53; 95% CI: [1.78, 3.59]. There were no significant differences in physician-verified diagnostic concerns or in integration of patient contributions into the note based on race, ethnicity, or language preference.CONCLUSION:Participants self-identifying as Black or "other" race, or those who prefer a language other than English were 1.5 to 2.5 times more likely than their counterparts to report potential diagnostic concerns when proactively asked to provide this information prior to a visit. Actively engaging patients and families in the DxP may uncover opportunities to reduce the risk of diagnostic errors and potential safety disparities.

Hypothesis: in near-term infants, a single, early, and persistantly low HsCRP level would be highly predictive of normal clinical outcome defined as negative blood culture, clinically well appearing infant, and less than 48 hours of treatment with antibiotics.Methods Used: Retrospective chart review of infants admitted to the NICU at Regional One Health in Memphis, TN from 03/01/19, until 09/30/21.Inclusion criteria were gestational age (GA) 34-36 weeks, started on antibiotics, and had serial HsCRPs collected.The 12-hr HsCRP time point was chosen to evaluate the hypothesis.Infants were divided based on a cutoff level of 0.3 mg/dL.The outcome measured was the Predictive Value of a 12-hour negative HsCRP in on the infant remaining well appearing at 48 hours and thus negating sepsis and further need of antibiotic treatment.Group 1 was defined as infants with a 12-hour HsCRP ≤0.30 mg/dL.Group 2 infants had their 12-hour HsCRP >0.30 mg/dL.Summary of Results: 199 infants were identified, table 1. Mean GA of 34 (± 0.8) weeks.Conditions commonly triggering antibiotic administration in both groups included respiratory distress, corioamnionitis, and need of resuscitation at birth.All infants had a negative blood culture except 1, positive for micrococcus.In group 1 with 12-hour HsCRP ≤0.30 mg/dL, 133/141 infants received ≤48 hours antibiotics.In group 2, 19/58 infants received >48 hours antibiotcs, figure 1.

© Author(s) (or their employer(s)) 2023. No commercial reuse. See rights and permissions. Published by BMJ. The purpose of BMJ Quality and Safety is to encourage the science of improvement, debate and new thinking on improving the quality of healthcare. Equity is a key domain of healthcare quality—high quality, safe healthcare should be available to all who need it. However, systemic biases and barriers are widespread in healthcare, as well as more broadly, including within the processes around the publication of research. For example, lack of diversity among editors, reviewers and authors of published papers is likely to both reflect and exacerbate systemic sources of inequity among researchers but also among the intended beneficiaries of our research—patients and their healthcare providers. By ‘diversity’, we here include areas such as (but not limited to) socioeconomic status, sex, gender, race or ethnicity, first language, sexual orientation, religion, beliefs, disability status, age, nationality or citizenship, and place of residence. At BMJ Quality and Safety, in addition to publishing papers on the quality and safety of healthcare, including equity, we are therefore committed to promoting and advancing equity in our editorial practices. Here we outline our commitments in this area as well as our future aspirations. We will consider in turn (1) the research that we publish, (2) our editorial practices and (3) the underpinning use of data to better understand the extent of the problems and to evaluate the impact of interventions in each of these areas. A summary of our aims in each of these three domains is presented in table 1.

Objective Patients and families are key partners in diagnosis, but methods to routinely engage them in diagnostic safety are lacking. Policy mandating patient access to electronic health information presents new opportunities. We tested a new online tool ("OurDX") that was codesigned with patients and families, to determine the types and frequencies of potential safety issues identified by patients/families with chronic health conditions and whether their contributions were integrated into the visit note. Methods Patients/families at 2 US healthcare sites were invited to contribute, through an online previsit survey: (1) visit priorities, (2) recent medical history/symptoms, and (3) potential diagnostic concerns. Two physicians reviewed patient-reported diagnostic concerns to verify and categorize diagnostic safety opportunities (DSOs). We conducted a chart review to determine whether patient contributions were integrated into the note. We used descriptive statistics to report implementation outcomes, verification of DSOs, and chart review findings. Results Participants completed OurDX reports in 7075 of 18 129 (39%) eligible pediatric subspecialty visits (site 1), and 460 of 706 (65%) eligible adult primary care visits (site 2). Among patients reporting diagnostic concerns, 63% were verified as probable DSOs. In total, probable DSOs were identified by 7.5% of pediatric and adult patients/families with underlying health conditions, respectively. The most common types of DSOs were patients/families not feeling heard; problems/delays with tests or referrals; and problems/delays with explanation or next steps. In chart review, most clinician notes included all or some patient/family priorities and patient-reported histories. Conclusions OurDX can help engage patients and families living with chronic health conditions in diagnosis. Participating patients/families identified DSOs and most of their OurDX contributions were included in the visit note.