SummaryBackgroundSelf-harm is one of the most common presentations at accident and emergency departments in the UK and is a strong predictor of suicide risk. The UK Government has prioritised identifying risk factors and developing preventative strategies for self-harm. Machine learning offers a potential method to identify complex patterns with predictive value for the risk of self-harm.MethodsNational data in the UK Mental Health Services Data Set were isolated for patients aged 18‒30 years who started a mental health hospital admission between Aug 1, 2020 and Aug 1, 2021, and had been discharged by Jan 1, 2022. Data were obtained on age group, gender, ethnicity, employment status, marital status, accommodation status and source of admission to hospital and used to construct seven machine learning models that were used individually and as an ensemble to predict hospital stays that would be associated with a risk of self-harm.OutcomesThe training dataset included 23 808 items (including 1081 episodes of self-harm) and the testing dataset 5951 items (including 270 episodes of self-harm). The best performing algorithms were the random forest model (AUC-ROC 0.70, 95%CI:0.66-0.74) and the ensemble model (AUC-ROC 0.77 95%CI:0.75-0.79).InterpretationMachine learning algorithms could predict hospital stays with a high risk of self-harm based on readily available data that are routinely collected by health providers and recorded in the Mental Health Services Data Set. The findings should be validated externally with other real-world data.FundingThis study was supported by the Midlands and Lancashire Commissioning Support Unit.Research in contextEvidence before this studyDespite self-harm being repeatedly labelled as a national priority for psychiatric healthcare research, it remains challenging for clinicians to stratify the risk of self-harm in patients. National guidelines have highlighted deficiencies in care and attention is being paid towards the use of large datasets to develop evidence-based risk stratification strategies. However, many of the tools so far developed rely upon elements of the patient’s clinical history, which requires well curated datasets at a population level and previous engagement with care services at an individual level. Reliance upon elements of a patient’s clinical history also risks biasing against patients with missing data or against hospitals where data is poorly recorded.Added value of this studyIn this study, we use commissioning data that is routinely collected in the United Kingdom by healthcare providers with each hospital admission. Of the variables that were available for analysis, recursive feature elimination optimised our variable selection to include only age group, source of hospital admission, gender, and employment status. Machine learning algorithms were able to predict hospital episodes in which patients self-harmed in the majority of cases using a national dataset. Random forest and ensemble machine learning methods were the best-performing models. Sensitivity and specificity at predicting self-harm occurrence were 0.756 and 0.596, respectively, for the random forest model and 0.703 and 0.730 for the ensemble model. To our knowledge, this is the first study of its kind and represents an advance in the prediction of inpatient self-harm by limiting the amount of information required to make predictions to that which would be near-universally available at the point of the admission, nationally.Implications of all the available evidenceThere is a role for machine learning to be used to stratify the risk of self-harm when patients are admitted to mental health facilities, using only commissioning data that is easily accessible at the point of care. External validation of these findings is required as whilst the algorithms were tested on a large sample of national data, there remains a need for prospective studies to assess the real-world application of such machine learning models.

Abstract Aim During surgical scrubbing, Sikhs in healthcare are often expected to remove their kara, a religious metal bangle. This seems inconsistent with policies permitting rings. As some Sikhs feel they cannot do this, they are refused entry to theatres. The aim of this quality improvement project is to explore if and how this exclusion might affect Sikhs and propose an inclusive solution accordingly. Method Working with MedRACE (a student-staff EDI group), we reviewed local and national infection and surgical scrubbing policies. We also distributed a survey nationally to explore Sikh medical students’ experiences in theatres, sharing our findings with local Trust leadership. Results We found variations in the policies reviewed, some permitting the kara, and others proposing removal or impossible solutions (‘secured…above the elbow’). Of 11 survey respondents, 9 had been told to remove their kara before entering theatres; 7 felt that wearing a kara limited their opportunities. Students reported that some Trusts (or staff) allowed them to wear a kara, whilst others did not. On presenting these findings to our local Trust, they updated the policy to permit the kara, and communicated this update to staff. Conclusions The national variation on wearing a kara in theatres is excluding some Sikhs from theatres. This may impact attainment and deter Sikhs from pursuing surgical careers. It is also at odds with the Royal College of Surgeon’s vision of creating a more inclusive surgical environment. We are thus planning further work to ensure greater consistency on this matter across the UK.

Trauma and orthopedics is a specialty in which significant blood loss can be incurred both in terms of traumatic injuries and operative management. This chapter starts with a brief review of the biology of hemostasis followed by the importance of hemostasis in surgery. This is followed by a discussion on the ideal hemostatic agent. Various strategies of achieving hemostasis will be discussed including mechanical, thermal, pharmacological and topical agents in both elective orthopedic and spine surgery as well as in trauma. Specifically, we will look at synthetic agents such as cyanoacrylate, polyethylene glycol hydrogel and glutaraldehyde cross-linked albumin and absorbable agents such as gelatin foams and oxidized cellulose. We will also look at biological agents such as topical thrombin, sealants and platelet gels. Hemostatic dressings will be discussed in detail.

BACKGROUND AND AIMS:Chronic pain is a potentially disabling condition affecting one in three people through impaired physical function and quality of life. While the psychosocial impact of chronic pain is already well established, little is known about the potential biological consequences. Chronic pain may be associated with an increased prevalence of cardiovascular disease, an effect that has been demonstrated across a spectrum of chronic pain conditions including low back pain, pelvic pain, neuropathic pain and fibromyalgia. The aim of this study was to review and summarize the evidence for a link between chronic pain and cardiovascular disease. We sought to clarify the nature of the relationship by examining the basis for a dose-response gradient (whereby increasing pain severity would result in greater cardiovascular disease), and by evaluating the extent to which potentially confounding variables may contribute to this association. METHODS:Major electronic databases MEDLINE, EMBASE, Psychinfo, Cochrane, ProQuest and Web of Science were searched for articles reporting strengths of association between chronic pain (pain in one or more body regions, present for three months or longer) and cardiovascular outcomes (cardiovascular mortality, cardiac disease, and cerebrovascular disease). Meta-analysis was used to pool data analysing the association between chronic pain and the three principal cardiovascular outcomes. The impact of pain severity, and the role of potentially confounding variables were explored narratively. RESULTS:The searches generated 11,141 studies, of which 25 matched our inclusion criteria and were included in the review. Meta-analysis (of unadjusted study outcomes) demonstrated statistically significant associations between chronic pain and mortality from cardiovascular diseases: pooled odds ratio 1.20, (95% confidence intervals 1.05-1.36); chronic pain and cardiac disease: pooled odds ratio 1.73 (95% confidence intervals 1.42-2.04); and chronic pain and cerebrovascular disease: pooled odds ratio 1.81 (95% confidence intervals 1.51-2.10). The systematic review also found evidence supporting a dose-response relationship, with greater pain intensity and distribution producing a stronger association with cardiovascular outcomes. All of the included studies were based on observational data with considerable variation in chronic pain taxonomy, methodology and study populations. The studies took an inconsistent and incomplete approach in their adjustment for potentially confounding variables, making it impossible to pool data after adjustments for confounding variables, so it cannot be concluded that these associations are causal. CONCLUSIONS:Our review supports a possible dose-response type of association between chronic pain and cardiovascular disease, supported by a range of observational studies originating from different countries. Such research has so far failed to satisfactorily rule out that the association is due to confounding variables. What is now needed are further population based longitudinal studies that are designed to allow more robust exploration of a cause and effect relationship. IMPLICATIONS:Given the high prevalence of chronic pain in developed and developing countries our results highlight a significant, but underpublicized, public health concern. Greater acknowledgement of the potentially harmful biological consequences of chronic pain may help to support regional, national and global initiatives aimed at reducing the burden of chronic pain.

Importance Improving patient safety is at the forefront of policy and practice. While considerable progress has been made in understanding the frequency, causes and consequences of error in hospitals, less is known about the safety of primary care.Objective We investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm.Evidence review We searched 18 databases and contacted international experts to identify published and unpublished studies available between 1 January 1980 and 31 July 2014. Patient safety incidents of any type were eligible. Eligible studies were critically appraised using validated instruments and data were descriptively and narratively synthesised.Findings Nine systematic reviews and 100 primary studies were included. Studies reported between <1 and 24 patient safety incidents per 100 consultations. The median from population-based record review studies was 2-3 incidents for every 100 consultations/records reviewed. It was estimated that around 4% of these incidents may be associated with severe harm, defined as significantly impacting on a patient's well-being, including long-term physical or psychological issues or death (range <1% to 44% of incidents). Incidents relating to diagnosis and prescribing were most likely to result in severe harm.Conclusions and relevance Millions of people throughout the world use primary care services on any given day. This review suggests that safety incidents are relatively common, but most do not result in serious harm that reaches the patient. Diagnostic and prescribing incidents are the most likely to result in avoidable harm.

BackgroundThere is an emerging interest in the inadvertent harm caused to patients by the provision of primary health-care services. To date (up to 2015), there has been limited research interest and few policy directives focused on patient safety in primary care. In 2003, a major investment was made in the National Reporting and Learning System to better understand patient safety incidents occurring in England and Wales. This is now the largest repository of patient safety incidents in the world. Over 40,000 safety incident reports have arisen from general practice. These have never been systematically analysed, and a key challenge to exploiting these data has been the largely unstructured, free-text data.AimsTo characterise the nature and range of incidents reported from general practice in England and Wales (2005–13) in order to identify the most frequent and most harmful patient safety incidents, and relevant contributory issues, to inform recommendations for improving the safety of primary care provision in key strategic areas.MethodsWe undertook a cross-sectional mixed-methods evaluation of general practice patient safety incident reports. We developed our own classification (coding) system using an iterative approach to describe the incident, contributory factors and incident outcomes. Exploratory data analysis methods with subsequent thematic analysis was undertaken to identify the most harmful and most frequent incident types, and the underlying contributory themes. The study team discussed quantitative and qualitative analyses, and vignette examples, to propose recommendations for practice.Main findingsWe have identified considerable variation in reporting culture across England and Wales between organisations. Two-thirds of all reports did not describe explicit reasons about why an incident occurred. Diagnosis- and assessment-related incidents described the highest proportion of harm to patients; over three-quarters of these reports (79%) described a harmful outcome, and half of the total reports described serious harm or death (n = 366, 50%). Nine hundred and ninety-six reports described serious harm or death of a patient. Four main contributory themes underpinned serious harm- and death-related incidents: (1) communication errors in the referral and discharge of patients; (2) physician decision-making; (3) unfamiliar symptom presentation and inadequate administration delaying cancer diagnoses; and (4) delayed management or mismanagement following failures to recognise signs of clinical (medical, surgical and mental health) deterioration.ConclusionsAlthough there are recognised limitations of safety-reporting system data, this study has generated hypotheses, through an inductive process, that now require development and testing through future research and improvement efforts in clinical practice. Cross-cutting priority recommendations include maximising opportunities to learn from patient safety incidents; building information technology infrastructure to enable details of all health-care encounters to be recorded in one system; developing and testing methods to identify and manage vulnerable patients at risk of deterioration, unscheduled hospital admission or readmission following discharge from hospital; and identifying ways patients, parents and carers can help prevent safety incidents. Further work must now involve a wider characterisation of reports contributed by the rest of the primary care disciplines (pharmacy, midwifery, health visiting, nursing and dentistry), include scoping reviews to identify interventions and improvement initiatives that address priority recommendations, and continue to advance the methods used to generate learning from safety reports.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

BACKGROUND: In the United Kingdom, 26% of child deaths have identifiable failures in care. Although children account for 40% of family physicians’ workload, little is known about the safety of care in the community setting. Using data from a national patient safety incident reporting system, this study aimed to characterize the pediatric safety incidents occurring in family practice. METHODS: We undertook a retrospective, cross-sectional, mixed methods study of pediatric reports submitted to the UK National Reporting and Learning System from family practice. Analysis involved detailed data coding using multiaxial frameworks, descriptive statistical analysis, and thematic analysis of a special-case sample of reports. Using frequency distributions and cross-tabulations, the relationships between incident types and contributory factors were explored. RESULTS: Of 1788 reports identified, 763 (42.7%) described harm to children. Three crosscutting priority areas were identified: medication management, assessment and referral, and treatment. The 4 incident types associated with the most harmful outcomes are errors associated with diagnosis and assessment, delivery of treatment and procedures, referrals, and medication provision. Poor referral and treatment decisions in severely unwell or vulnerable children, along with delayed diagnosis and insufficient assessment of such children, featured prominently in incidents resulting in severe harm or death. CONCLUSION: This is the first analysis of nationally collected, family practice–related pediatric safety incident reports. Recommendations to mitigate harm in these priority areas include mandatory pediatric training for all family physicians; use of electronic tools to support diagnosis, management, and referral decision-making; and use of technological adjuncts such as barcode scanning to reduce medication errors.

IntroductionIncident reports contain descriptions of errors and harms that occurred during clinical care delivery. Few observational studies have characterised incidents from general practice, and none of these have been from the England and Wales National Reporting and Learning System. This study aims to describe incidents reported from a general practice care setting.Methods and analysisA general practice patient safety incident classification will be developed to characterise patient safety incidents. A weighted-random sample of 12 500 incidents describing no harm, low harm and moderate harm of patients, and all incidents describing severe harm and death of patients will be classified. Insights from exploratory descriptive statistics and thematic analysis will be combined to identify priority areas for future interventions.Ethics and disseminationThe need for ethical approval was waivered by the Aneurin Bevan University Health Board research risk review committee given the anonymised nature of data (ABHB R&D Ref number: SA/410/13). The authors will submit the results of the study to relevant journals and undertake national and international oral presentations to researchers, clinicians and policymakers.

Mbeledogu et al 1 demonstrate a reduction in unintentional poisonings in children in England, yet highlight the protracted social disparities among these children. This resonates with our exploration of over 20 000 paediatric safety incidents from primary care in England and Wales where the ‘Inverse Care Law’ features prominently.2 These reports include: looked-after children, immigrants, travellers, parents with addiction problems and those belonging to other disadvantaged groups. Data mining identified over 500 reports involving these groups and 33 reports involving homeless children or families. Such a reporting system has not previously been used to assess unsafe care in socially deprived groups. Thematic analysis of free-text in reports involving homeless children was undertaken and five overarching failures were identified (see table 1). Some disclosure failures resulted in …

In 2013, as many as 6·3 million children worldwide died before their fifth birthday.1 Children have an increased risk of health-care-related harm because of factors including the complexity of prescribing and dispensing of drugs, a reduced physiological reserve compared with adults, and dependency on others (ie, parents and health-care providers) to recognise the emergence of a hazardous situation.2 Despite these factors, little research has been done of the contributions of substandard care and iatrogenic harm to deaths in childhood.

Aim Healthcare failures have been identified in 26% of UK child deaths. Despite children accounting for 40% of general practitioners’ workload, little is known about the safety of care in the community setting. Using data from a national reporting system, this study aimed to characterise the paediatric safety incidents occurring in general practice to inform a logic model with identified priorities for clinical practice improvement. Methods We undertook a retrospective cross-sectional mixed methods study utilising paediatric reports submitted to the National Reporting and Learning System from general practice (2003–2013). Analysis involved a detailed data coding process using multi-axial frameworks combined with descriptive statistical analysis, and thematic analysis of all reports of severe harm and death. A 20% sample of reports were independantly double coded and kappa statistics of inter-rater reliability were calculated. Using frequency distributions and cross-tabulations the relationships between incident types and contributory factors were explored. Clusters of contributory factors were identified. Subject matter experts identified primary and secondary drivers for improvement. Results 1,788 reports were identified with 763 (42.7%) describing harm to children. Four priority areas–incidents associated with the most harmful outcomes–include errors associated with: medication management; timely referral of unwell children; delivery of safe evidence-based treatment; and, adequate diagnosis and assessment. Poor referral and treatment decisions in severely unwell or vulnerable children, along with delayed diagnosis and insufficient assessment of such children, featured prominently in incidents resulting in severe harm or death. The factors contributing to these incidents form the bases of our recommendations for improvement and are illustrated in a logic model (see Figure 1). Conclusion This is the first analysis of nationally–collected general practice–related paediatric safety incident reports. Recommendations to mitigate harm in these priority areas include: mandatory paediatric training for all general practitioners; utilising electronic tools to support diagnosis, management and referral decision-making; and use of tools such as bar code scanning to reduce medication errors. Practitioners are encouraged to reflect on these recommendations, as well as explore their own local safety report data to identify additional priorities for practice improvement.