Introduction:The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact in Asia and has placed significant burden on already stretched healthcare systems. We examined the impact of COVID-19 on the safety attitudes among healthcare workers (HCWs), as well as their associated demographic and occupational factors, and measures of burnout, depression and anxiety.Methods:A cross-sectional survey study utilising snowball sampling was performed involving doctors, nurses and allied health professions from 23 hospitals in Singapore, Malaysia, India and Indonesia between 29 May 2020 and 13 July 2020. This survey collated demographic data and workplace conditions and included three validated questionnaires: the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory and Hospital Anxiety and Depression Scale. We performed multivariate mixed-model regression to assess independent associations with the SAQ total percentage agree rate (PAR).Results:We obtained 3,163 responses. The SAQ total PARs were found to be 35.7%, 15.0%, 51.0% and 3.3% among the respondents from Singapore, Malaysia, India and Indonesia, respectively. Burnout scores were highest among respondents from Indonesia and lowest among respondents from India (70.9%-85.4% vs. 56.3%-63.6%, respectively). Multivariate analyses revealed that meeting burnout and depression thresholds and shifts lasting >= 12 h were significantly associated with lower SAQ total PAR.Conclusion:Addressing the factors contributing to high burnout and depression and placing strict limits on work hours per shift may contribute significantly towards improving safety culture among HCWs and should remain priorities during the pandemic.

Correspondence to Dr Thomas Handley, Department of Health Policy, Stanford University School of Medicine, Stanford, USA;thandley@stanford.edu The COVID-19 pandemic tested how healthcare organisations allocate economic, staffing and infrastructural resources, demonstrating that we operate in a resource-constrained environment. Quality improvement, on the other hand, refers to the process of making something better, often within a rigid structure, for example, ‘Plan, Do, Study, Act': generating a stepwise process to identify an issue, test an intervention, collect data and adjust the process as needed.7 There are specific subtypes of quality improvement, such as ‘LEAN', developed in the manufacturing industry to improve process efficiency by removing extraneous steps.8 Still, each differs from the mathematical ‘maximise or minimise' approach that defines optimisation techniques. Applying these techniques can lead to better staff satisfaction, more efficient service delivery, and ultimately, better patient outcomes.Table 1 Worked example giving components required to optimise the number of patients seen in an emergency department Elements Plain language description Mathematical description Decision Variables How many staff to hire? How many nurses to staff? N (nurses) How many doctors to staff? D (doctors) Parameters Cost of shift A nurse shift costs £400 Cost=400N A doctor Shift costs £500 Cost=500D Expected patients 200 patients are expected P (patients) = 200 Speed A nurse sees 4 patients per hour Speed=4N A doctor sees 2 patients per hour Speed=2D Constraints Budget The total cost of doctors plus nurses must be less than 20 000 (400N+500D) <20 000 Staff ratio Patient to nurse ratio must be less than 4 P/N<4 Patient to doctor ratio must be less than 8 P/D<8 Objective Speed Maximise the rate of seeing patients Max (speed)=max (4N+2D) Express Checkout Optimisation is a mathematical technique to aid healthcare leaders in making decisions about resource allocation.

Background The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles. Methods We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment. Results Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment. Conclusions Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

Background COVID-19 was declared a worldwide pandemic on 11 March 2020. Imperial College Healthcare NHS Trust provides 1412 inpatient beds staffed by 1200 junior doctors and faced a large burden of COVID-19 admissions.Local problem A survey of doctors revealed only 20% felt confident that they would know to whom they could raise concerns and that most were getting information from a combination of informal work discussions, trust emails, social media and medical literature.Methods This quality improvement project was undertaken aligning with Standards for Quality Improvement Reporting Excellence 2.0 guidelines. Through an iterative process, a digital network (Imperial Covid cOmmunications Network; ICON) using existing smartphone technologies was developed. Concerns were collated from the junior body and conveyed to the leadership team (vertical—bottom-up using Google Form) and responses were conveyed from leadership to the junior body (vertical—top-down using WhatsApp and Zoom). Quantitative analysis on engagement with the network (members of the group and number of issues raised) and qualitative assessment (thematic analysis on issues) were undertaken.Results Membership of the ICON WhatsApp group peaked at 780 on 17 May 2020. 197 concerns were recorded via the Google Form system between 20 March and 14 June 2020. There were five overarching themes: organisational and logistics; clinical strategy concerns; staff safety and well-being; clinical (COVID-19) and patient care; and facilities. 94.4% of members agreed ICON was helpful in receiving updates and 88.9% agreed ICON improved collaboration.Conclusions This work demonstrates that a coordinated network using existing smartphone technologies and a novel communications structure can improve collaboration between senior leadership and junior doctors. Such a network could play an important role during times of pressure in a healthcare system.

Abstract Introduction The WHO Global Patient Safety Challenge aims to reduce severe avoidable medication-related harm by 50% by 2023[1]. Research suggests that providing timely, trusted feedback that incorporates relevant action can improve practice. However, a key barrier is lack of prescribing error data. Hospital electronic prescribing (EP) data may help address this gap. Aims To explore approaches for continuously monitoring medication safety signals using existing or new EP data, and to deliver personalised prescribing feedback and learning to improve patient safety. Methods We conducted a feasibility study (November 2019 - February 2020) on a 28-bed adult gastroenterology. This ward was chosen because of a high prescribing error rate. All foundation year 1 and 2 doctors, and pharmacists on the ward, participated in the study. The study team comprised pharmacists, doctors, quality improvement experts and clinical analysts, and used a quality improvement approach to design and test (i) methods for extracting electronic data to calculate prescribing accuracy rates, (ii) ways to refine a paper-prototype of an electronic pharmacists’ interventions form, (iii) potential digital medication safety indicators, and (iv) approaches for feedback for doctors to augment existing verbal feedback from pharmacists. Data were documented in accordance with local information governance and analysed using Excel. Acceptability and usability was assessed through verbal feedback from participants during weekly huddles. Outcome measures: feasibility of using EP to determine prescribing accuracy, user acceptability and usability of data collection, feedback and learning by pharmacists and doctors. We also measured changes in prescribing accuracy rate, pharmacists’ interventions, and quality of prescribing for targeted problematic medications. Results Extracting EP data required multiple data linkages to be configured and validated, and not all required data were available. Potential digital medication safety indicators: utility of the reason code ‘prescribed in error’ and actions by pharmacists to modify medications were limited by underuse and lack of data granularity. After testing different ways to extract relevant EP data, we eventually used a combination of EP and manual retrospective review of electronic patient records to determine prescribing accuracy rates. An intervention form was redesigned to tally interventions and capture details for contextual learning for email feedback to doctors and weekly prescribing improvement huddles. Doctors reported emails as timely and helpful for gaining new prescribing- and system-related knowledge. Pharmacists reported intervention data as providing invaluable evidence to drive improvement. Statistical process control charts showed no special cause variation around a mean prescription accuracy rate of 98% for inpatient orders, and 87% for discharge orders. By contrast, pharmacists recorded a mean of 10 interventions/day with 7 special cause variation (above upper control limit of 19) in the first two months. Omission of venous thromboembolism prophylaxis was identified as a priority medication issue. Specific prescriber- and system-based improvements were suggested (Jan 2020), some implemented (Feb 2020) and others fed back to the thrombosis committee (Feb 2020). Conclusion Harnessing the potential of EP data to improve medication safety requires the workforce to have a deeper understanding of the EP data structure and processes. Using a quality improvement approach, we developed a feedback and learning model that is acceptable and useful to pharmacists and doctors. Further research should explore adapting the approach to other clinical areas. Reference 1. Sheikh, A., Dhingra-Kumar, N., Kelley, E., Kieny, M. and Donaldson, L. The Third Global Patient Safety Challenge: Tackling Medication-Related Harm. Bulletin of the World Health Organization. World Health Organisation. 2017;95:546-546A.

OBJECTIVES:The strain on health care systems due to the COVID-19 pandemic has led to increased psychological distress among health care workers (HCWs). As this global crisis continues with little signs of abatement, we examine burnout and associated factors among HCWs.DESIGN:Cross-sectional survey study.SETTING AND PARTICIPANTS:Doctors, nurses, allied health professionals, administrative, and support staff in 4 public hospitals and 1 primary care service in Singapore 3 months after COVID-19 was declared a global pandemic.METHODS:Study questionnaire captured demographic and workplace environment information and comprised 3 validated instruments, namely the Oldenburg Burnout Inventory (OLBI), Safety Attitudes Questionnaire (SAQ), and Hospital Anxiety and Depression Scale (HADS). Multivariate mixed model regression analyses were used to evaluate independent associations of mean OLBI-Disengagement and -Exhaustion scores. Further subgroup analysis was performed among redeployed HCWs.RESULTS:Among 11,286 invited HCWs, 3075 valid responses were received, giving an overall response rate of 27.2%. Mean OLBI scores were 2.38 and 2.50 for Disengagement and Exhaustion, respectively. Burnout thresholds in Disengagement and Exhaustion were met by 79.7% and 75.3% of respondents, respectively. On multivariate regression analysis, Chinese or Malay ethnicity, HADS anxiety or depression scores ≥8, shifts lasting ≥8 hours, and being redeployed were significantly associated with higher OLBI mean scores, whereas high SAQ scores were significantly associated with lower scores. Among redeployed HCWs, those redeployed to high-risk areas in a different facility (offsite) had lower burnout scores than those redeployed within their own work facility (onsite). A higher proportion of HCWs redeployed offsite assessed their training to be good or better compared with those redeployed onsite.CONCLUSIONS AND IMPLICATIONS:Every level of the health care workforce is susceptible to high levels of burnout during this pandemic. Modifiable workplace factors include adequate training, avoiding prolonged shifts ≥8 hours, and promoting safe working environments. Mitigating strategies should target every level of the health care workforce, including frontline and nonfrontline staff. Addressing and ameliorating burnout among HCWs should be a key priority for the sustainment of efforts to care for patients in the face of a prolonged pandemic.

The Covid-19 pandemic has placed unprecedented pressure on healthcare systems and workers around the world. Such pressures may impact on working conditions, psychological wellbeing and perception of safety. In spite of this, no study has assessed the relationship between safety attitudes and psychological outcomes. Moreover, only limited studies have examined the relationship between personal characteristics and psychological outcomes during Covid-19. From 22nd March 2020 to 18th June 2020, healthcare workers from the United Kingdom, Poland, and Singapore were invited to participate using a self-administered questionnaire comprising the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory (OLBI) and Hospital Anxiety and Depression Scale (HADS) to evaluate safety culture, burnout and anxiety/depression. Multivariate logistic regression was used to determine predictors of burnout, anxiety and depression. Of 3,537 healthcare workers who participated in the study, 2,364 (67%) screened positive for burnout, 701 (20%) for anxiety, and 389 (11%) for depression. Significant predictors of burnout included patient-facing roles: doctor (OR 2.10; 95% CI 1.49-2.95), nurse (OR 1.38; 95% CI 1.04-1.84), and 'other clinical' (OR 2.02; 95% CI 1.45-2.82); being redeployed (OR 1.27; 95% CI 1.02-1.58), bottom quartile SAQ score (OR 2.43; 95% CI 1.98-2.99), anxiety (OR 4.87; 95% CI 3.92-6.06) and depression (OR 4.06; 95% CI 3.04-5.42). Significant factors inversely correlated with burnout included being tested for SARS-CoV-2 (OR 0.64; 95% CI 0.51-0.82) and top quartile SAQ score (OR 0.30; 95% CI 0.22-0.40). Significant factors associated with anxiety and depression, included burnout, gender, safety attitudes and job role. Our findings demonstrate a significant burden of burnout, anxiety, and depression amongst healthcare workers. A strong association was seen between SARS-CoV-2 testing, safety attitudes, gender, job role, redeployment and psychological state. These findings highlight the importance of targeted support services for at risk groups and proactive SARS-CoV-2 testing of healthcare workers.

Introduction: Bullying within the NHS costs billions and impacts on patient safety, quality of care and patient satisfaction. Although bullying is anecdotally widespread, to date the experience amongst general surgery specialty trainees has not been fully evaluated in London. The purpose of this study was to determine the prevalence amongst London trainees and evaluate the impact on their career.

Introduction Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and in turn patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. Methods The Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture during Covid-19 at a large UK teaching hospital. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. Results Significant increases were seen in SAQ score for doctors and AHPs (p value) from baseline (p value). A decrease in SAQ was found in the nursing group. Largely due to perception of management and safety climate subscales. During Covid-19, on univariate regression analysis, female gender (p<0.001), age 40-49 years (p<0.01), non-white ethnicity (p<0.001), nursing job role (p<0.001) were all associated with lower SAQ scores. Training (p<0.001) and support (p<0.001) for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (-0.13, -0.26-0.00), non-disclosed ethnicity (-0.11, -0.22-0.00), nursing role (-0.15, -0.24-0.06), and support (0.24, 0.07-0.4) persisted to significance. A significant decrease (p<0.003) was seen in error reporting after the onset of the Covid-19 pandemic. Discussion Differences in reported safety culture may reflect perception of risk due to: occupational exposure, job function, or access to support services. Reductions in incident reporting may be due to increased workload, change in nature of work, or changing safety attitudes. Targeted high-quality support for redeployed staff may help improve safety during future pandemics.

The traditional model for surgical research typically involves generating incremental improvements in clinical outcomes either through the optimization of existing approaches, or through the introduction of novel techniques. This process is often painstakingly slow1 with a significant time lag from the initial development of an idea, through to the delivery of a highly controlled trial and subsequent clinical translation.2–4 In many instances, this resource consuming process may not produce an agreed conclusion nor be widely adopted within routine practice. Surgical research is absolutely necessary during a pandemic to guide surgical treatment during the pandemic, to prepare surgical services for what is to come after the pandemic, and the next stages of healthcare recovery. The current COVID-19 pandemic5,6 has demonstrated that the existing paradigm of surgical research, predominantly reliant upon incremental innovation, is not fit for this purpose. As such, to prevent avoidable harm, we must now urgently adapt from a rigid system of highly controlled prospective trials, towards an adaptive and pragmatic approach, which is focused upon delivering agile evidence-based changes in practice at pace and scale. To achieve this, we must be cognizant of the specific challenges that lie ahead and the strategies that we must champion so that we may overcome them. RESEARCH CHALLENGES DURING A PANDEMIC Global crisis such as COVID-19, exert intolerable stress on the delivery of clinical research, which is typically compromised as clinical scientists are redirected to the front line. This represents a significant threat to the process of clinical research; safe and effective care is only possible if critical learning systems are maintained and trials can be deployed to demonstrate efficacy of emerging therapies for novel threats. Modern research is multidisciplinary, and surgeons are often critical players that not only provide samples, but important insights into experimental design, analysis, execution, and leadership. Research in a time of crisis must also address system wide challenges. First, like any other service it requires effective leadership with a command and control structure. This has been strikingly absent, and it is now critical that global funding bodies and our professional associations pick up the ball and take the initiative.7 We urgently require clear priorities and networks around which clinical research can be coordinated. Time remains a significant limiting factor in this pandemic, particularly because of the speed of transmission which has caught many governments and healthcare providers off guard.8 As a result, critical functions of research, such as ethical approvals, must be acquired under immense pressure. This process is further compounded by limited capacity within research infrastructures to adapt to staff becoming unwell or the loss of administrative staff. Similarly, clinical academics will face increasing demands in service provision leaving limited bandwidth to dedicate to research. Some of these challenges are predictable, but many are not, and a global crisis of this magnitude means that both research networks and systems may be unreliable, and patient responses to both established and new surgical interventions may vary dramatically. Therefore, confounders may strongly influence outcomes seen during a pandemic. However, during a crisis many barriers to research also come down, facilitating widespread collaboration within and between units on an international scale. During the COVID-19 pandemic, there is evidence of trials in medical therapies,9 prevention strategies,10 and vaccines.11 Surgeons now urgently require the same approach if we are to optimize the treatment of surgical pathology and protect our staff. But, even during times of crisis balance between rapid dissemination and robust scientific methodology is required if robust work of impact is to be produced. Moreover, it must be communicated and synthesized at pace. Many journals, including Annals of Surgery, have changed their publication process to facilitate learning and create new models of content distribution. Teams are finding new ways of working through digital platforms and social networks, and there has never been more data and computing power available to clinicians who have to solve some of our biggest problems. ETHOS OF SURGICAL RESEARCH During a pandemic, the ethos of surgical research must change. The traditional model of scientific investigation and peer-reviewed publication must swiftly adapt to the fast moving pace of the disease, aiming to achieve greater understanding with quality improvement measures, rapid dissemination, and clinical implementation to maximize the quality of care we deliver to our patients. Not doing so risks the propagation of falsehoods and nonevidence based practice. STRATEGIES FOR SURGICAL RESEARCH DURING A PANDEMIC A new tailored approach to surgical research that aims to address the pandemic crisis should include four key principles. First, collaborative learning is essential to the success of any surgical project. New digital technologies with a national, and more importantly, a global reach can serve as incredibly useful forums for discussion and shared learning across countries and health systems as they enter different stages in their pandemic response. These are important to support the widespread dissemination of new knowledge and allow learned experiences to be shared amongst healthcare professionals. The PanSurg collaborative,12 an international collaboration of clinical academics who are coordinating targeted COVID-19 studies, have sought to address this knowledge gap by hosting webinars with subject matter experts from a variety of backgrounds. The most common question that panelists in these webinars are asked is, “if you knew what you know now four weeks ago, what would you do differently?” The answers to this question are vitally important to health systems in which the pandemic has started later, allowing them to implement change early, avoid making the same mistakes and reduce unnecessary morbidity by interrupting the vicious spiraling cycle of disease sooner. These lessons must be centrally collated and communicated. Second, novel sources of reliable information and opportunities for rapid dissemination of findings need to be sought. The traditional process of peer-review just takes too long, and is not dynamic enough to keep up with the rapidly changing context of a pandemic. Conversely, social media platforms, utilization of preprints, and other online resources allow for faster dissemination, with the potential for more timely clinical adoption and subsequent impact. When adopted in conjunction with open and transparent online discussion and critique, they also provide a degree of “real-time” peer-review and debate. This model caters for the delivery of robust evidence to inform effective decision-making. Third, it is vital to remember that data is key to surgical research during a pandemic. Data capture must be focused to limit collection and entry fatigue, but also robust enough to permit meaningful analysis. Focused analytics during pandemics may include the generation of novel dynamic risk prediction models13; these can serve to guide clinical decision making and the allocation of limited resources such as choice of intervention and intensive care unit bed utilization. The modeling of risk during a pandemic is challenging for two important reasons; (i) the disease itself may change the risk associated with surgical intervention (often increasing risk), and (ii) healthcare resources will be stretched beyond any previous situation and thus cannot be modeled from historical data. Importantly, processes for the review and approval of such data collection and analysis must also adapt to ensure that vital data and time is not lost. The fourth principle involves engagement with industry; this is one of the major strengths of technology-focused surgical research and may provide a common model upon which to base new relationships. During a pandemic the traditional funding model is not fit for purpose; the process of applying for a research grant, gaining funding, and implementing a project is far too time consuming. Transparent engagement with industry will allow shared learning and pooling of resource, the introduction of new expertise, and the rapid delivery of additional funding to support surgical research and new initiatives in a dynamic way. CONCLUSIONS The rapidly evolving and progressing nature of the present COVID-19 pandemic has highlighted several critical limitations in the traditional model of surgical research; namely, the inability to provide timely evidence to rapidly inform and change clinical practice, thus ultimately defeating its main purpose of improving patient outcomes. The key question remains the same; “how do we deliver the best possible care for our patients?” What has changed; however, is that the novel context of a rapidly evolving pandemic which necessitates speed in dissemination and clinical implementation. The traditional approach to surgical research must evolve to cater for (1) iterative learning, (2) novel dissemination methods, (3) rapid data generation, and (4) industry collaboration to meet the current pandemic challenge.

Summary:. Lower pole breast cancers are challenging to manage because conventional wide local excision may produce a “bird’s beak” deformity. In an era of oncoplastic surgery, techniques that balance oncological results with cosmetic outcomes such as local flaps have extended the role of breast-conserving surgery. Local flaps are particularly useful for partial breast reconstruction due to the relative simplicity of the surgical procedure and reduced morbidity. Intercostal artery perforator flaps have a shorter duration of surgery than free flaps and do not require microsurgical anastomoses. Anterior intercostal artery perforator (AICAP) flaps provide excellent cosmesis, yet traditional crescenteric harvest yields limited volume for reconstruction. We describe a modification to an established reconstructive technique for lower pole breast defects. The technique is based on 3 extensions of tissue, providing a larger volume of tissue replacement compared with traditional AICAP flaps. The technique is particularly suitable for small- and medium-sized non-ptotic breasts, with lower pole tumors. The modified crescenteric AICAP technique can be used to increase the available tissue when performing lower pole reconstructions.

BackgroundThere is a need to understand the impact of COVID-19 on colorectal cancer care globally and determine drivers of variation.ObjectiveTo evaluate COVID-19 impact on colorectal cancer services globally and identify predictors for behaviour change.DesignAn online survey of colorectal cancer service change globally in May and June 2020.ParticipantsAttending or consultant surgeons involved in the care of patients with colorectal cancer.Main outcome measuresChanges in the delivery of diagnostics (diagnostic endoscopy), imaging for staging, therapeutics and surgical technique in the management of colorectal cancer. Predictors of change included increased hospital bed stress, critical care bed stress, mortality and world region.Results191 responses were included from surgeons in 159 centers across 46 countries, demonstrating widespread service reduction with global variation. Diagnostic endoscopy was reduced in 93% of responses, even with low hospital stress and mortality; whilst rising critical care bed stress triggered complete cessation (p = 0.02). Availability of CT and MRI fell by 40-41%, with MRI significantly reduced with high hospital stress. Neoadjuvant therapy use in rectal cancer changed in 48% of responses, where centers which had ceased surgery increased its use (62 vs 30%, p = 0.04) as did those with extended delays to surgery (p<0.001). High hospital and critical care bed stresses were associated with surgeons forming more stomas (p<0.04), using more experienced operators (p<0.003) and decreased laparoscopy use (critical care bed stress only, p<0.001). Patients were also more actively prioritized for resection, with increased importance of co-morbidities and ICU need.ConclusionsThe COVID-19 pandemic was associated with severe restrictions in the availability of colorectal cancer services on a global scale, with significant variation in behaviours which cannot be fully accounted for by hospital burden or mortality.

Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and, in turn, with patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. The Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture at a large UK healthcare trust during Covid-19. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. SAQ scores of doctors and “other clinical staff”, were relatively higher than the nursing group. During Covid-19, on univariate regression analysis, female gender, age 40–49 years, non-White ethnicity, and nursing job role were all associated with lower SAQ scores. Training and support for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (−0.13), non-disclosed ethnicity (−0.11), nursing role (−0.15), and support (0.29) persisted to a level of significance. A significant decrease (p < 0.003) was seen in error reporting after the onset of the Covid-19 pandemic. This is the first study to investigate SAQ during Covid-19. Differences in SAQ scores were observed during Covid-19 between professional groups when compared to baseline. Reductions in incident reporting were also seen. These changes may reflect perception of risk, changes in volume or nature of work. High-quality support for redeployed staff may be associated with improved safety perception during future pandemics.

Trauma represents a major global health problem projected to increase in importance over the next decade. The majority of deaths occur in low- and middle-income countries (LMICs) where survival rates are lower than their high-income country (HIC) counterparts. Health system level changes in care for injured patients have been attributed to significant improvements in care quality and outcomes in HIC settings. There is a need for further research to assess trauma care health systems in LMICs to inform health system strengthening for the care of the injured. This study aims to conduct a narrative synthesis of a systematic search of the literature on the assessment of trauma care health systems in LMICs in order to inform the further development of trauma care health system assessment. The review will include primary quantitative, qualitative or mixed method studies and secondary literature reviews. No restriction will be placed on language or date. Reports and publications identified from the grey literature including from relevant national and international health organisations will be included. Articles will be screened by two independent reviewers with a third reviewer resolving any persisting disagreement. The search will reveal heterogenous studies not suitable for meta-analysis. A narrative synthesis of the identified papers will be conducted to identify key methodological ideas and paradigms used to assess trauma care health systems. The analysis will consider how the differing methodological approaches could be adopted to understand barriers and delays to seeking, reaching and receiving care within a “Three Delays” framework. An iterative approach will be adopted to categorise identified articles, with the results presented as both within and across study analysis. The results of the review will be disseminated through publication in a peer-reviewed academic journal. The study forms part of a PhD project. The results will inform the development of a trauma care health system assessment applicable to LMICs. As this is a review of secondary data, no formal ethical approval is required. PROSPERO CRD42018112990

PURPOSE:Active patient participation in safety pathways has demonstrated benefits in reducing preventable errors, especially in relation to hand hygiene and surgical site marking. The authors sought to examine patient participation in a range of safety-related behaviours as well as factors that influence this, such as gender, education, age and language.DESIGN:A 20-point questionnaire was employed in a London teaching hospital to explore safety-related behaviours, particularly assessing patient's willingness to challenge healthcare professionals and engagement in taking an active role in their own care while in hospital. Data was also collected on participant demographic details including gender, age, ethnicity, English language proficiency and education status.RESULTS:85% of the 175 patients surveyed would consider bringing a list of their medications to hospital, but only 60% would bring a list of previous surgeries. Only 45% would actively engage in the WHO Safer Surgery Checklist and over three quarters (80%) would not challenge doctors and nurses regarding hand hygiene, believing that they would cause offence. Female patients who had tertiary education, were fluent in English and less than 60 years of age were statistically more likely to feel responsible for their own safety and take an active role in safety-related behaviour while in hospital (p<0.05).CONCLUSIONS:Many patients are not engaged in safety-related behaviour and do not challenge healthcare professionals on safety issues. Older male patients who were not tertiary educated or fluent in English need to be empowered to take an active role in such behaviour. Further research is required to investigate how to achieve this.

Background An estimated 8 50 000 cases of unintentional medical injuries occur every year, at least half of which are thought to be preventable. Patients receiving palliative care are particularly vulnerable to medical errors and their consequences. Patient participation in their own safety has well-demonstrated benefits in reducing errors. Understanding how patients feel about participating in their own safety and how to improve patient engagement could help reduce medical errors in palliative care. The authors sought to examine patient participation in a range of safety-related behaviours and investigate how they varied with different patient demographics. Methods A 20-point questionnaire was employed exploring safety-related behaviours, particularly looking at patient willingness to challenge healthcare professionals and to notify them of potential errors. Data on sex, age, ethnicity, English language proficiency, duration in the United Kingdom, employment and education status was also collected. Results 195 patients were invited to participate in this study and 175 patients completed the questionnaire. Female patients who had tertiary education, those who were fluent in English and under the age of 60 years were statistically more likely to feel responsible for their own safety and take an active role in their safety. Older male patients of lower education status are statistically less likely to question staff on hand hygiene. Conclusion Despite numerous campaigns to improve patient involvement many still do not participate in their own safety. Patients without tertiary education, patients over 60, and those who are not fluent in English are much less willing to challenge healthcare professionals about safety-related issues. Understanding the impact of patient demographics on participation in safety behaviours could help to create novel, more targeted strategies to improve patient safety. This could effectively reduce preventable medical errors in palliative care medicine where patients are more vulnerable to such errors.

Introduction: In response to a serious incident involving an atrial fibrillation (AF) associated stroke, a quality improvement project was established to examine and improve all aspects of patient care for individuals presenting with acute AF to London’s North Middlesex University Hospital (NMUH).Materials and Methods: The presenting complaint was examined for 2,105 consecutive medical admissions to identify 100 patients (4.7%) with acute AF. For each patient, 36 indices and performance indicators were collected and analysed against international standards. Deficiencies were identified in documentation, risk stratification, anticoagulation and arrhythmia management decisions. With cross-specialty collaboration, a single-page AF management algorithm was established using sequential PDSA methodology, and a further 100 consecutive patients with acute AF were analysed prospectively. A composite end-point of adverse outcomes (AF-associated readmission, stroke, cardiac death or major bleeding) was examined.Results: Algorithm implementation significantly reduced the proportion of patients exposed to unnecessary stroke risk (30% vs 4%, p<0.0001); improved identification and documentation of thromboembolic potential (50% vs 88%, p<0.0001), reduced incorrect drug decisions (12% vs 2%, p=0.01), reduced contraindicated rhythm control (8% vs 0%, p=0.007), and increased direct oral anticoagulant (DOAC) prescribing (38% vs 86%, p<0.0001) over warfarin. After a mean follow-up of 248 +/- 91 days, there was a significant reduction in composite adverse outcomes (22% vs 6%, p=0.0018).Conclusion: Using established quality improvement methodology and cost-neutral multi-disciplinary expertise, this novel management algorithm has significantly improved the quality and safety of care for patients with acute AF at NMUH.