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Introduction Patient safety problems stemming from healthcare represent a significant cause of morbidity and mortality globally. The evidence base on safety in mental healthcare, particularly regarding community-based mental health services, has long fallen behind that of physical healthcare, with fewer research publications, developed primarily in isolation from the wider improvement science discipline. This disconnect both yields, and stems from, conceptual and practical challenges which must be surmounted in order to advance the science and improvement of safety in mental healthcare. Objectives The objectives of this research were to conduct a narrative review to provide an overview of conceptual issues in this area, their origins, and implications for patient safety science and clinical care. We also sought to identify approaches to overcoming these issues. Methods We examined theoretical and empirical evidence from the fields of patient safety, mental health, and improvement science to address this knowledge gap. Results We identified challenges with defining safety in the context of community mental healthcare, ascertaining what constitutes a ‘preventable’ safety problem requiring intervention, and in finding relevant research evidence. The research indicated that risk management has taken precedence over proactive safety promotion in mental healthcare. This positions service users as the origin of safety risks, with iatrogenic harm and latent system hazards associated with mental healthcare widely overlooked. Conclusions We propose a broader conceptualisation of safety to advance the field and outline potential next steps for the integration and uptake of different sources of ‘safety intelligence’ within community mental health services. Disclosure NS is the director of London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no competing interests.

Introduction There is limited existing research about patient safety issues in mental healthcare. A lack of evidence is particularly pronounced in relation to safety in community-based mental health services, where the majority of care is provided. To date, reviews of mental health patient safety literature have focused primarily on inpatient care settings. Objectives This systematic scoping review will aim to identify and synthesise literature about the types of patient safety problems in adult community-based mental health settings, the causes of these problems, and evaluated safety interventions in this care context. Methods A systematic search was conducted on 19th June 2020 and refreshed on 23rd October 2021, across five databases: Medline, Embase, PsycINFO, Health Management Information Consortium, and Cumulative Index to Nursing and Allied Health Literature. The search strategy focused on three key elements: ‘mental health’, ‘patient safety’ and ‘community-based mental health services’. Retrieved articles were screened at title, abstract and subject heading level, followed by full-text screen of longlisted articles. Results In this presentation, the findings of this systematic scoping review will be described, based on synthesised literature about safety incidents, broader care delivery problems, their causes, and evaluated patient safety interventions to address these issues. Conclusions This study will offer learning opportunities about the safety problems, contributory factors, and safety interventions in adult community-based mental health services, as described in the evidence base. Review findings will also help to ascertain gaps in existing research, which should be addressed in future studies. Disclosure NS is the director of London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no competing interests.

Introduction Existing research has seldom examined patient safety problems experienced by service users accessing community mental healthcare, with the growing evidence base focusing largely on safety in psychiatric inpatient settings. Accordingly, there is poor understanding of safety issues in community-based mental health services as perceived by service users, carers, and healthcare professionals. Objectives This study aims to explore safety problems in adult community-based mental health services, their causation, and priority areas for improving the safety of care provided in these services. Methods In-depth, semi-structured interviews and focus groups were conducted with users of community-based mental health services, carers, and healthcare professionals employed within these settings. Interview topic guides were designed jointly with stakeholders from these groups (N=7) and piloted (N=3). Interviews and focus groups will be transcribed, coded, and analysed using an inductive thematic analysis approach. Illustrative quotes will be extracted and used to describe the key themes that emerge from the analysis and their inter-relationships. Results This presentation will provide an outline of patient safety as understood and experienced by key stakeholder groups. Study findings will explicate safety issues, healthcare system factors underpinning their causation, as well as practices which could improve safety in this context. Conclusions This research will help to advance understanding of the nature of patient safety problems in community-based mental healthcare services for adults, based on the experiences of service users, carers, and healthcare professionals within these services. The research will address key evidence gaps and represents an important step towards identifying areas which warrant intervention to improve patient safety. Disclosure NS is the director of London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no competing interests.

Research, collaboration, and knowledge exchange are critical to global efforts to tackle antimicrobial resistance (AMR). Different healthcare economies are faced with different challenges in implementing effective strategies to address AMR. Building effective capacity for research to inform AMR-related strategies and policies is recognised as an important contributor to success. Interdisciplinary, intersector, as well as international collaborations are needed to span global to local efforts to tackle AMR. The development of reciprocal, long-term partnerships between collaborators in high-income and in low- and middle-income countries (LMICs) needs to be built on principles of capacity building. Using case studies spanning local and international research collaborations to codesign, implement, and evaluate strategies to tackle AMR, we have evaluated and build upon the ESSENCE criteria for capacity building in LMICs. The first case study describes the local codesign and implementation of antimicrobial stewardship (AMS) in the state of Kerala in India. The second case study describes an international research collaboration investigating AMR surgical patient pathways in India, the UK, and South Africa. We describe the steps undertaken to develop robust, agile, and flexible AMS research and implementation teams. Notably, investing in capacity building ensured that the programmes described in these case studies were sustained through the current severe acute respiratory syndrome coronavirus pandemic. Describing the strategies adopted by a local and an international collaboration to tackle AMR, we provide a model for capacity building in LMICs that can support sustainable and agile AMS programmes.

Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement.

Objective: To study experiences of women who gave birth in maternity units that have implemented a 'care bundle' quality improvement initiative to reduce obstetric anal sphincter injury (OASI) and associated morbidity., Design: Postnatal electronic questionnaire., Setting: Twenty-nine maternity units across England, Scotland and Wales., Population: Women with live vaginal births., Methods: Descriptive statistics for quantitative results. Analysis of free-text responses informed by framework method., Main Outcome Measures: Experience with components of the care bundle: information provision, manual perineal protection (MPP) and post-birth rectal examination., Results: In this study, 1208 women completed the survey: 684 (56.6%) said they received antenatal information about perineal health, 377 (31.2%) recalled MPP, and 664 (55.0%) recalled rectal examination. Of the 684 women who said they received antenatal information, 595 (87.0%) agreed that the information was easy to understand, and 423 (61.8%) agreed that it helped them to make their own choices to reduce their OASI risk. One hundred and fifty-four (22.5%) agreed that the information made them fearful about giving birth vaginally. Of the 377 women who recalled MPP, 203 (53.9%) felt it provided them with support, and another 97 (25.7%) did not mind the sensation. Of the 664 women who recalled rectal examination, 281 (42.3%) did not mind the exam, and another 335 (50.5%) felt it was uncomfortable but understood its importance. Free-text responses aligned with quantitative results., Conclusions: Many women did not recall MPP or rectal examination. The reported experiences for those who recalled these components do not support concerns that the OASI care bundle has negative effects on women's experiences., (© 2024 The Author(s). BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Aims and Method: A collaborative evaluation of remote consultations in mental health services was undertaken by mental health service providers, experts by experience, academic institutions and a Health Innovation Network in south London, UK. 'Learning healthcare systems' thinking was applied. Workstream 1 reviewed international published evidence; workstream 2 synthesised findings from three health provider surveys of the perceptions and experiences of staff, patients and carers; and workstream 3 comprised an electronic survey on local projects., Results: Remote consultations can be acceptable to patients and staff. They improve access for some while restricting access for others, with digital exclusion being a key concern. Providing tailored choice is key., Clinical Implications: The collaboration generated learning to inform choices by healthcare providers to embed or adapt remote delivery. A key output was freely downloadable survey questions for assessing the quantity and quality of appointments undertaken by phone or video or face to face.

Background: People of African and Caribbean heritage in the UK have a higher prevalence of Type 2 Diabetes (T2D) and poorer health outcomes than white Europeans. Healthy Eating and Active Lifestyles for Diabetes Online (HEAL-D Online) is a co-designed, culturally tailored T2D self-management programme for black African and Caribbean adults, which, due to online delivery, is well positioned for spread. This qualitative evaluation uses the Exploration-Preparation-Implementation-Sustainment (EPIS) framework to explore factors affecting scale-up from delivery and commissioning perspectives., Methods: Semi-structured interviews were conducted with nine commissioners and providers of T2D services from three English areas with varying population characteristics to explore scale-up. Focus groups were held with 15 people of African and Caribbean heritage with T2D lived experience to explore the impact of a digital model of participation. Data were analysed using thematic analysis, with themes mapped onto the EPIS framework exploration phase constructs to consider the outer and inner contextual factors for planning implementation., Results: Six EPIS constructs were identified by commissioners and providers as key in scaling HEAL-D Online. People with T2D lived experience explored the online mode of delivery, using the patient advocacy construct as the analytical lens. In delivering an online T2D programme, two themes were identified: (1) aligning course content with people's preferences; (2) practicalities to ensure online delivery was acceptable and accessible to the community., Conclusions: HEAL-D Online was acceptable with the potential to help address health inequalities. The EPIS framework provided a structure to understand factors in planning scale-up for an intervention targeting underserved communities., (© 2024 The Author(s). Journal of Human Nutrition and Dietetics published by John Wiley & Sons Ltd on behalf of British Dietetic Association.)

Objectives: To assess the feasibility and acceptability of delivering Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) Online., Intervention: HEAL-D Online-a 7-week culturally tailored type 2 diabetes educational programme delivered using online platform., Setting: Programme delivered by a London NHS trust, with patients referred from primary care healthcare professionals via a central booking system., Participants: 53 HEAL-D service users completed a postcourse questionnaire, and 14 service users and 7 service delivery staff participated in interviews., Design: Mixed methods service evaluation., Primary and Secondary Outcomes: Service user engagement, acceptability and perceived patient benefit assessed using service activity data. Feasibility and acceptability of HEAL-D Online, using semi-structured interviews to explore the views and experiences of service users and service delivery staff., Results: Service activity data showed that initial uptake of HEAL-D Online was good (62% attendance) with a high adherence to the programme (77% completion). A high fidelity (94%) was observed, and qualitative findings showed that staff and service users were satisfied with all aspects of course delivery. Both service activity and qualitative data indicated that attendees felt more confident in controlling their diet and managing their diabetes post-HEAL-D Online., Conclusion: This evaluation demonstrates the feasibility of delivering HEAL-D using an online platform, with its ability to achieve similar goals compared with its face-to-face counterpart. Challenges were identified around the identification, recruitment and referral of eligible patients into the programme, which need to be addressed for successful implementation on a wider scale., Competing Interests: Competing interests: NS is the director of London Safety and Training Solutions, which offers training and improvement and implementation solutions to healthcare organisations and the pharmaceutical industry. JTSL, SL, LMG, SI, OB, NC and AW have no conflicts of interest to declare., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: People with severe mental illness (SMI) have worse physical health than the general population. There is evidence that support from volunteers can help the mental health of people with SMI, but little evidence regarding the support they can give for physical health., Aims: To evaluate the feasibility of an intervention where volunteer 'Health Champions' support people with SMI in managing their physical health., Method: A feasibility hybrid randomised controlled trial conducted in mental health teams with people with SMI. Volunteers delivered the Health Champions intervention. We collected data on the feasibility of delivering the intervention, and clinical and cost-effectiveness. Participants were randomised by a statistician independent of the research team, to either having a Health Champion or treatment as usual. Blinding was not done., Results: We recruited 48 participants: 27 to the intervention group and 21 to the control group. Data were analysed for 34 participants. No changes were found in clinical effectiveness for either group. Implementation outcomes measures showed high acceptability, feasibility and appropriateness, but with low response rates. No adverse events were identified in either group. Interviews with participants found they identified changes they had made to their physical health. The cost of implementing the intervention was £312 per participant., Conclusions: The Health Champion intervention was feasible to implement, but the implementation of the study measures was problematic. Participants found the intervention acceptable, feasible and appropriate, and it led them to make changes in their physical health. A larger trial is recommended, with tailored implementation outcome measures.

Objectives: This study evaluated the scale-up of a remote monitoring service, capturing monthly Rheumatoid Arthritis Impact of Disease scores and patient-generated text messages, for patients with rheumatoid arthritis (RA; in remission or with low disease activity) attending routine outpatient clinics across six hospitals. We explored patients and staff experiences and implementation outcomes., Methods: A pragmatic, mixed methods approach was used, with active patient involvement throughout. We undertook a rapid review, analysed service-level data, and conducted a patient survey and patient and staff interviews, informed by the Capability, Opportunity, Motivation, Behaviour (COM-B) and Exploration, Preparation, Implementation, Sustainment (EPIS) theoretical frameworks., Results: The review included 37 articles, covering themes of patient and clinician acceptability, engagement, feasibility and clinical impact. Service-level data (n = 202) showed high levels of patient engagement with the service. The patient survey (n = 155) showed patients felt the service was easy to use, had confidence in it and felt it improved access to care. Patient interview (n = 22) findings mirrored those of the survey. Motivating factors included increased responsiveness and ease of contact with clinical teams. Views from staff interviews (n = 16) were more mixed. Some implementation barriers were specific to roll-out sites. Prioritization of staff needs was emphasized., Conclusion: Patients were positive about the service and engagement was high. Staff views and engagement were more mixed. Results suggest that equal levels of patient and staff engagement are required for sustainability. These findings further our understanding of the implementation challenges to scaling remote monitoring interventions for patients with rheumatoid arthritis in routine care settings., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Background: Having traditionally received limited attention in empirical research and safety improvement agendas, issues of patient safety in mental healthcare increasingly feature in healthcare quality improvement discourses. Dominant approaches to safety stem from narrow clinical risk management perspectives, yet existing evidence points to the limitations of this characterisation. Although mental healthcare is increasingly delivered in community-based settings, narratives of safety pertain primarily to hospital-based mental healthcare. Therefore, through exploratory qualitative interviews and one focus group, we aimed to examine how service users, carers, and healthcare providers conceptualise 'patient safety' in community-based mental healthcare., Methods: Semi-structured interviews and a single focus group were conducted with users of UK community-based mental healthcare provision for adults (n = 13), their carers (n = 12), and providers (n = 18), who were diverse in characteristics and experiences. Study data were analysed in accordance with a reflexive approach to thematic analysis., Findings: Four key themes were developed, reflecting contrasting conceptualisations of safety in this care context, where participant thinking evolved throughout discussions. 'Systemic inertia: threats to safety' characterises the entrenched, systemic challenges which rendered participants powerless to advocate for or deliver safe care. 'Managing the risks service users present' equates 'safe care' to the mitigation of risks service users may pose to themselves or others when unwell, or risks from those around them. 'More than responding to risks: everyone plays a role in creating safety' recognises providers' agency in causing or proactively preventing patient harm. Finally, 'The goals of 'safety': our destination is not yet in sight' positions safety as a work in progress, calling for ambitious safety agendas, giving primacy to goals which meaningfully improve service users' lives., Conclusions: Our findings have implications for the understanding and improvement of patient safety in community-based mental healthcare settings, where improvement objectives should transcend beyond management of risks and preventing deterioration to address patient and carer-centred concerns, including practices that make people feel unsafe., (© 2024. The Author(s).)

Artificial intelligence (AI) use in diabetes care is increasingly being explored to personalise care for people with diabetes and adapt treatments for complex presentations. However, the rapid advancement of AI also introduces challenges such as potential biases, ethical considerations, and implementation challenges in ensuring that its deployment is equitable. Ensuring inclusive and ethical developments of AI technology can empower both health-care providers and people with diabetes in managing the condition. In this Review, we explore and summarise the current and future prospects of AI across the diabetes care continuum, from enhancing screening and diagnosis to optimising treatment and predicting and managing complications., Competing Interests: Declaration of interests NS is the director of London Safety and Training Solutions. HL is supported by the National Key Research and Development Program of China (2022YFA1004804), the Excellent Young Scientists Fund of the National Natural Science Foundation of China (82022012), and the innovative research team of high-level local universities in Shanghai (SHSMU-ZDCX20212700). Y-CT is supported by the National Medical Research Council of Singapore (NMRC/MOH/ HCSAINV21nov-0001)., (Copyright © 2024 Published by Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Purpose: This systematic review focuses on the effectiveness, safety, and implementation outcomes of light therapy as an intervention to prevent or control myopia in children., Methods: A systematic literature search was performed in PubMed, EMBASE, CINAHL, SCOPUS, and Web of Science up to January 27, 2024. Effectiveness outcomes included myopia incidence, and changes in axial length (AL), spherical equivalent refraction (SER), and choroidal thickness (CT). Safety outcomes relating to retinal health or damage and implementation outcomes including compliance rates and loss to follow-up were extracted. ROBINS-I, ROB 2, and ROB-2 CRT were used to assess risk of bias., Results: Nineteen interventional studies were included. Increased outdoor time (n = 3), red-light therapy (n = 13), and increased classroom lighting (n = 1) had a significant effect on myopia incidence, and changes in AL, SER, and CT. Violet-light therapy (n = 2) was only effective in children aged 8 to 10 years and children without eyeglasses with less than 180 minutes of near-work time daily. Two studies using red-light therapy reported adverse effects. For all studies, only compliance rates and loss to follow-up were reported on implementation effectiveness., Conclusions: Evidence is compelling for the effectiveness of red-light therapy and outdoors time; more data are needed to confirm safety. Robust data are still needed to prove the effectiveness of violet-light and increased classroom lighting. Clearer implementation strategies are needed for all light therapies., Translational Relevance: Light therapy has emerged as effective for myopia prevention and control. This systematic review summarizes the state of knowledge and highlights gaps in safety and implementation for these strategies.

Background: The Ethiopian Primary Healthcare Clinical Guidelines (EPHCG) seek to improve quality of primary health care, while also expanding access to care for people with Non-Communicable Diseases and Mental Health Conditions (NCDs/MHCs). The aim of this study was to identify barriers and enablers to implementation of the EPHCG with a particular focus on NCDs/MHCs., Methods: A mixed-methods convergent-parallel design was employed after EPHCG implementation in 18 health facilities in southern Ethiopia. Semi-structured interviews were conducted with 10 primary healthcare clinicians and one healthcare administrator. Organisational Readiness for Implementing Change (ORIC) questionnaire was self-completed by 124 health workers and analysed using Kruskal Wallis ranked test to investigate median score differences. Qualitative data were mapped to the Consolidated Framework for Implementation Science (CFIR) and the Theoretical Domains Framework (TDF). Expert Recommendations for Implementing Change (ERIC) were employed to select implementation strategies to address barriers., Results: Four domains were identified: EPHCG training and implementation, awareness and meeting patient needs (demand side), resource constraints/barriers (supply side) and care pathway bottlenecks. The innovative facility-based training to implement EPHCG had a mixed response, especially in busy facilities where teams reported struggling to find protected time to meet. Key barriers to implementation of EPHCG were non-availability of resources (CFIR inner setting), such as laboratory reagents and medications that undermined efforts to follow guideline-based care, the way care was structured and lack of familiarity with providing care for people with NCDs-MHCs. Substantial barriers arose because of socio-economic problems that were interlinked with health but not addressable within the health system (CFIR outer setting). Other factors influencing effective implementation of EPHCG (TDF) included low population awareness about NCDs/MHCs and unaffordable diagnostic and treatment services (TDF). Implementation strategies were identified. ORIC findings indicated high scores of organisational readiness to implement the desired change with likely social desirability bias., Conclusion: Although perceived as necessary, practical implementation of EPHCG was constrained by challenges across domains of internal/external determinants. This was especially marked in relation to expansion of care responsibilities to include NCDs/MHCs. Attention to social determinants of health outcomes, community engagement and awareness-raising are needed to maximize population impact., (© 2024. The Author(s).)

Introduction: Many patient safety practices are only partly established in routine clinical care, despite extensive quality improvement efforts. Implementation science can offer insights into how patient safety practices can be successfully adopted., Objective: The objective was to examine the literature on implementation of three internationally used safety practices: medication reconciliation, antibiotic stewardship programmes and rapid response systems. We sought to identify the implementation activities, factors and outcomes reported; the combinations of factors and activities supporting successful implementation; and the implications of the current evidence base for future implementation and research., Methods: We searched Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Education Resources Information Center from January 2011 to March 2023. We included original peer-reviewed research studies or quality improvement reports. We used an iterative, inductive approach to thematically categorise data. Descriptive statistics and hierarchical cluster analyses were performed., Results: From the 159 included studies, eight categories of implementation activities were identified: education; planning and preparation; method-based approach; audit and feedback; motivate and remind; resource allocation; simulation and training; and patient involvement . Most studies reported activities from multiple categories. Implementation factors included: c linical competence and collaboration; resources; readiness and engagement; external influence; organisational involvement; QI competence; and feasibility of innovation . Factors were often suggested post hoc and seldom used to guide the selection of implementation strategies. Implementation outcomes were reported as: fidelity or compliance; proxy indicator for fidelity; sustainability; acceptability; and spread . Most studies reported implementation improvement, hindering discrimination between more or less important factors and activities., Conclusions: The multiple activities employed to implement patient safety practices reflect mainly method-based improvement science, and to a lesser degree determinant frameworks from implementation science. There seems to be an unexploited potential for continuous adaptation of implementation activities to address changing contexts. Research-informed guidance on how to make such adaptations could advance implementation in practice., Competing Interests: Competing interests: All authors have completed the ICMJE form for disclosure of competing interests. JTO, ES, SH, HVW have been supported in their work on this paper by grants from the Research Council of Norway, the Western Norway Regional Health Authority, and the Bergen Hospital Trust. MH has been supported in her work on this paper by grants from the Research Council of Norway, and by employment as a researcher by the Fonna Hospital Trust. SH has headed the reference group for the Norwegian Patient Safety Campaign (2011–2014, honorary without payment), and is a paid member of the Regional Committee for Medical Ethics since 2021. PEA has coauthored this paper as part of his work at the Norwegian Centre for Antiobiotic Use in Hospitals, Haukeland University Hospital. He is also an editor of the national guidelines for antibiotic use in hospitals, member of the editorial board of the national guidelines for antibiotic use in primary care, and member of the national breakpoint committee, all without extra funding, as part of his ordinary work. NS has recieved consulting fees as director of London Safety and Training Solutions. RKL has coauthored this paper salaried as an academic librarian at the University of Bergen., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Aims: To assess the cost-effectiveness of HARPdoc (Hypoglycaemia Awareness Restoration Programme for adults with type 1 diabetes and problematic hypoglycaemia despite optimised care), focussed upon cognitions and motivation, versus BGAT (Blood Glucose Awareness Training), focussed on behaviours and education, as adjunctive treatments for treatment-resistant problematic hypoglycaemia in type 1 diabetes, in a randomised controlled trial., Methods: Eligible adults were randomised to either intervention. Quality of life (QoL, measured using EQ-5D-5L); cost of utilisation of health services (using the adult services utilization schedule, AD-SUS) and of programme implementation and curriculum delivery were measured. A cost-utility analysis was undertaken using quality-adjusted life years (QALYs) as a measure of trial participant outcome and cost-effectiveness was evaluated with reference to the incremental net benefit (INB) of HARPdoc compared to BGAT., Results: Over 24 months mean total cost per participant was £194 lower for HARPdoc compared to BGAT (95% CI: -£2498 to £1942). HARPdoc was associated with a mean incremental gain of 0.067 QALYs/participant over 24 months post-randomisation: an equivalent gain of 24 days in full health. The mean INB of HARPdoc compared to BGAT over 24 months was positive: £1521/participant, indicating comparative cost-effectiveness, with an 85% probability of correctly inferring an INB > 0., Conclusions: Addressing health cognitions in people with treatment-resistant hypoglycaemia achieved cost-effectiveness compared to an alternative approach through improved QoL and reduced need for medical services, including hospital admissions. Compared to BGAT, HARPdoc offers a cost-effective adjunct to educational and technological solutions for problematic hypoglycaemia., (© 2024 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Introduction: Being on a waiting list for elective (planned) cardiac surgery can be physically and psychologically challenging for patients. Research suggests that stress associated with waiting for surgery is dependent on different individual and contextual factors. However, most data on patients' experiences of waiting for surgery and preferences for waiting list management derives from non-cardiac clinical populations. The aim of the current study is to explore patients' experiences of being on a waiting list for elective cardiac surgery, and their views on how the waiting experience could be improved in the future. This work will inform the patient management strategy during the waiting period for surgery across the four major hospitals in London directly involved in this study, and potentially beyond by transferring learning to other services., Methods and Analysis: This is a mixed-methods study that will collect quantitative and qualitative data using a cross-sectional online survey. Patients who are on waiting lists for elective surgery across four major cardiac surgery departments in London hospitals, and are at least 18 years old, will be invited by their healthcare team via text message or letter to complete the survey. The target sample size of non-randomly selected participants will be 268. Bivariable and multivariable regression models will be used to assess associations between survey items measuring the impact of the cardiac condition on specific life domains (eg, daily activities, social and family relationships, hobbies, sexual life), anxiety and depression symptoms as measured by the Patient Health Questionnaire-4 and survey items evaluating experiences of health services. Data on experience and preferences for improvements to the waiting experience will be analysed with qualitative content analysis using an inductive approach., Ethics and Dissemination: This study was reviewed and granted ethical approval by the East of England-East Cambridge Research Ethics Committee. Findings from this study will be disseminated through peer-reviewed journals, a research website and social media and with an online event engaging patients, members of the public, healthcare professionals and other relevant stakeholders., Trial Registration Numb: NCT05996640., Competing Interests: Competing interests: NS is the director of London Safety and Training Solutions, which offers training and improvement and implementation solutions to healthcare organisations and the pharmaceutical industry., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Leadership in a safety culture environment is essential in avoiding patient harm. However, leadership in surgery is not routinely taught or assessed. This study aims to identify a framework, metrics and tools to improve surgical leadership and safety outcomes., Methods: Qualitative interviews were performed with leadership experts from safety-critical professions. Non-probability-based sampling was undertaken in major international airlines. Data underwent thematic analysis and clinical adaptation by multiple surgeon-analysts using the framework method., Results: 583 codes were synthesised into 10 themes. Leaders were identified as 'threat and error managers' who placed safety first. Their core attribute was humble confidence. This allowed them to set the tone for high standards of practice, whilst empowering individuals to speak up about safety issues. Safety-oriented leaders assumed complete responsibility and applied their authority discerningly to obtain optimal outcomes. Finally, effective leaders rallied support for their mission by instilling confidence, building collaborations and managing conflict., Conclusions: Surgical leadership requires the ability to manage risk, opportunity and people. The study provides an assessment matrix and deliverable tools for improving surgical safety., Competing Interests: Declaration of competing interest Manuscript and research sources of funding: This study was not internally or externally funded General Funding statement not directly applicable to this work: Nick Sevdalis' research is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King's College Hospital NHS Foundation Trust. NS is a member of King's Improvement Science, which offers co-funding to the NIHRARC South London and comprises a specialist team of improvement scientists and senior researchers based at King's College London. Its work is funded by King's Health Partners (Guy's and St Thomas' NHS Foundation Trust, King's College Hospital NHS Foundation Trust, King's College London and South London and Maudsley NHS Foundation Trust), Guy's and St Thomas' Charity and the Maudsley Charity. Nick Sevdalis' research is further supported by the ASPIRES research programme (Antibiotic use across Surgical Pathways - Investigating, Redesigning and Evaluating Systems), funded by the Economic and Social Research Council. Nick Sevdalis is further funded by the National Institute of Health Research (NIHR)Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa, King's College London (GHRU 16/136/54) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, the ESRC or the Department of Health and Social Care. Nizam Mamode reports grants and consultancy funding from Hansa. These were all for activities outside the remit of this work. P Gogalniceanu, B Kunduzi and C Ruckley report no funding. COI statement: Nick Sevdalis is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations. The other authors have no conflicts of interest to declare. AI: No AI tools were used in the data analysis or writing of this manuscript., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: To date, beneficial effects of multimodal exercise programmes on Parkinson's disease (PD) have focused on motor symptoms and little attention has been paid to the potential effects of such programmes on the non-motor symptoms of PD, which are now universally known as one of the key drivers of quality of life and a key unmet need. We aim to explore clinical effectiveness of a ballet-based dance programme in addressing non-motor and motor symptoms of Parkinson's disease across all stages of progression., Methods: A randomised, single-blind, controlled trial of 160 people with Parkinson's across all motor stages (Participants will be stratified into three groups of motor advancement: Hoehn and Yahr (HY) stages I and II being Mild Group, HY Stage III being Moderate Group and HY Stages IV and V being Severe Group) will be randomly allocated to either an intervention or a control group using an independent randomisation body. The primary outcome is an improvement in non-motor symptoms as measured by the Movement Disorders Society Non-Motor Scale (MDS-NMS). The intervention protocol consists of 12 one-weekly dance sessions led by English National Ballet. Each session is followed by a 'tea and biscuit' social time. Control group follows standard clinical pathway and joins the 'tea and biscuit' to control for any positive effects of social interactions. All participants are assessed at baseline, immediately after completion of the intervention and 3-6 months later to explore any potential longitudinal effects., Discussion: To our knowledge, no adequately powered study has explored the effects of a dance-based intervention on non-motor symptoms of Parkinson's disease, assessing these on both holistic and granular levels. We also aim to stratify participants in accordance with their motor state as assessed by. HY staging to explore specific effects on the symptoms at the initial, moderate and complex stages of the disease. If successful, this trial provides first evidence on clinical effectiveness of a ballet-based dance intervention for symptoms of Parkinson's disease, assessed in a robust, rigorous manner., Trial Registration: NCT04719468., (© 2023. The Author(s).)

Background: Multi-disciplinary behavioral research on acute care teams has focused on understanding how teams work and on identifying behaviors characteristic of efficient and effective team performance. We aimed to define important knowledge gaps and establish a research agenda for the years ahead of prioritized research questions in this field of applied health research., Methods: In the first step, high-priority research questions were generated by a small highly specialized group of 29 experts in the field, recruited from the multinational and multidisciplinary "Behavioral Sciences applied to Acute care teams and Surgery (BSAS)" research network - a cross-European, interdisciplinary network of researchers from social sciences as well as from the medical field committed to understanding the role of behavioral sciences in the context of acute care teams. A consolidated list of 59 research questions was established. In the second step, 19 experts attending the 2020 BSAS annual conference quantitatively rated the importance of each research question based on four criteria - usefulness, answerability, effectiveness, and translation into practice. In the third step, during half a day of the BSAS conference, the same group of 19 experts discussed the prioritization of the research questions in three online focus group meetings and established recommendations., Results: Research priorities identified were categorized into six topics: (1) interventions to improve team process; (2) dealing with and implementing new technologies; (3) understanding and measuring team processes; (4) organizational aspects impacting teamwork; (5) training and health professions education; and (6) organizational and patient safety culture in the healthcare domain. Experts rated the first three topics as particularly relevant in terms of research priorities; the focus groups identified specific research needs within each topic., Conclusions: Based on research priorities within the BSAS community and the broader field of applied health sciences identified through this work, we advocate for the prioritization for funding in these areas., (© 2024. The Author(s).)

Introduction: CARISEL is an implementation-effectiveness "hybrid" study examining the perspectives of people living with HIV-1 (patient study participants [PSPs]) on cabotegravir (CAB) plus rilpivirine (RPV) long-acting (LA) dosed every 2 months (Q2M) across 5 European countries., Methods: PSPs completed questionnaires on acceptability (Acceptability of Intervention Measure), appropriateness (Intervention Appropriateness Measure), and feasibility (Feasibility of Intervention Measure) at their first (Month [M] 1), third (M4), and seventh (M12) injection visits. Semistructured qualitative interviews were also conducted., Results: Overall, 437 PSPs were enrolled, of whom 430 received treatment. Median (interquartile range) age was 44 (37-51) years, 25.3% (n = 109/430) were female (sex at birth), and 21.9% (n = 94/430) were persons of color. Across time points, PSPs found CAB + RPV LA highly acceptable, appropriate, and feasible (mean scores ≥4.47/5). Qualitative data supported these observations., Conclusions: PSPs found CAB + RPV LA Q2M to be an acceptable, appropriate, and feasible treatment option., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CAG, RM, RT, JS, MP-B, MA-K, BH, AdR, PM and MC are employees of ViiV Healthcare and may be stockholders of GSK. MvdV has received research grants and fees for participation in advisory boards from ViiV, MSD and Gilead. JP reports grants from Gilead and ViiV Healthcare and payments from lectures from Gilead and Janssen. EJ has received speaking fees or consulting activities from ViiV and Gilead laboratories and hospitality and congress registrations from ViiV, Gilead, MSD and Pfizer laboratories. LB and TL have no conflicts of interest to report. SBA, ELL, MH and NB are employees of Evidera who were paid by GSK/ViiV Healthcare to conduct the CARISEL study. NS is the director of London Safety and Training Solutions Ltd, which offers training and improvement and implementation solutions to healthcare organisations and the pharmaceutical industry.

People with severe mental illness (SMI) are more likely to experience physical health conditions than the general population. Little is known about the experience of people with SMI using digital health interventions (DHIs) to support their physical health. We explored how people with SMI use DHIs to support their physical health, the acceptability, factors affecting use, and impact on physical health. This was a three-stage mixed methods study (1) online survey of people with SMI; (2) interviews with a subsample of participants from Stage 1; (3) stakeholder workshops. Participants were generally satisfied with the DHIs they used. The most popular DHIs were targeted at diet, exercise, and weight management. Factors that encouraged use included simplicity and data-linkage. Concerns included costs, data security, and reliability of information. Positive impacts included accountability and tangible physical health benefits. Mental health impacted engagement with DHIs. DHIs were seen as a useful tool to monitor physical health but could not replace contact with clinical services. DHIs were considered useful and acceptable by people with SMI and may be used as an extension of clinical care. The specific needs and priorities of people with SMI should be considered both in developing and recommending interventions.

Background: Informal caregivers of people with dementia (PwD) living at home are often the primary source of care, and, in their role, they often experience loss of quality of life. Implementation science knowledge is needed to optimize the real-world outcomes of evidence-based interventions (EBIs) for informal caregivers. This scoping review aims to systematically synthesize the literature that reports implementation strategies employed to deliver home- and community-based EBIs for informal caregivers of PwD, implementation outcomes, and the barriers and facilitators to implementation of these EBIs., Methods: Embase, MEDLINE, Web of Science, and Cochrane Library were searched from inception to March 2021; included studies focused on "implementation science," "home- and community-based interventions," and "informal caregivers of people with dementia." Titles and abstracts were screened using ASReview (an innovative AI-based tool for evidence reviews), and data extraction was guided by the ERIC taxonomy, the Implementation Outcome Framework, and the Consolidated Framework for Implementation Science Research; each framework was used to examine a unique element of implementation., Results: Sixty-seven studies were included in the review. Multicomponent (26.9%) and eHealth (22.3%) interventions were most commonly reported, and 31.3% of included studies were guided by an implementation science framework. Training and education-related strategies and provision of interactive assistance were the implementation strategy clusters of the ERIC taxonomy where most implementation strategies were reported across the reviewed studies. Acceptability (82.1%), penetration (77.6%), and appropriateness (73.1%) were the most frequently reported implementation outcomes. Design quality and packaging (intervention component suitability) and cosmopolitanism (partnerships) constructs, and patient's needs and resources and available resources (infrastructure) constructs as per the CFIR framework, reflected the most frequently reported barriers and facilitators to implementation., Conclusion: Included studies focused largely on intervention outcomes rather than implementation outcomes and lacked detailed insights on inner and outer setting determinants of implementation success or failure. Recent publications suggest implementation science in dementia research is developing but remains in nascent stages, requiring future studies to apply implementation science knowledge to obtain more contextually relevant findings and to structurally examine the mechanisms through which implementation partners can strategically leverage existing resources and regional networks to streamline local implementation. Mapping local evidence ecosystems will facilitate structured implementation planning and support implementation-focused theory building., Trial Registration: Not applicable., (© 2023. The Author(s).)

Background: Mental health acute and crisis care consumes a large share of mental health budgets internationally but is often experienced as unsatisfactory and difficult to access. As a result, there is an increasing move towards developing innovative community crisis services, to improve patient experience and relieve pressure on inpatient and emergency services. This study aims to understand what helps and hinders the implementation of innovative mental health crisis care projects in England., Methods: Using a qualitative approach, 18 interviews were conducted with crisis care service managers exploring their experiences and views of the development and implementation of their service developed with support from an English national capital funding programme. A framework analysis was conducted informed by implementation science., Results: Key facilitators to implementation of innovative crisis services included bottom-up development, service user involvement, strong collaborative working, and leadership and management buy-in. Key barriers that affected the projects implementation included the complexities of crisis care, workforce challenges and resourcing issues., Conclusion: There is a recognised need to improve, update, and innovate current crisis care offers. Results from this study suggest that a range of models can help address the heterogenous needs of local populations and that new approaches can be implemented where they utilise a whole-systems approach, involving service users and relevant professional stakeholders beyond mental health services in planning and developing the service., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Introduction: Setting mental health priorities helps researchers, policy makers, and service funders improve mental health services. In the context of a national mental health implementation programme in England, this study aims to identify implementable evidence-based interventions in key priority areas to improve mental health service delivery., Methods: A mixed-methods research design was used for a three step prioritisation approach involving systematic scoping reviews (additional manuscript under development), expert consultations and data triangulation. Groups with diverse expertise, including experts by experience, worked together to improve decision-making quality by promoting more inclusive and comprehensive discussions. A multi-criteria decision analysis (MCDA) model was used to combine participants' varied opinions, data and judgments about the data's relevance to the issues at hand during a decision conferencing workshop where the priorities were finalised., Results: The study identified mental health interventions in three mental health priority areas: mental health inequalities, child and adolescent mental health, comorbidities with a focus on integration of mental and physical health services and mental health and substance misuse problems. Key interventions in all the priority areas are outlined. The programme is putting some of these evidence-based interventions into action nationwide in each of these three priority mental health priority areas., Conclusion: We report an inclusive attempt to ensure that the list of mental health service priorities agrees with perceived needs on the ground and focuses on evidence-based interventions. Other fields of healthcare may also benefit from this methodological approach if they need to make rapid health-prioritisation decisions., Competing Interests: NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Ahuja, Phillips, Smartt, Khalid, Coldham, Fischer, Rae, Sevdalis, Boaz, Robinson, Gaughran, Lelliott, Jones, Thornicroft, Munshi, Drummond, Perez and Littlejohns.)

Background: Postnatal depression (PND) affects over 12% of mothers, with numbers rising during COVID-19. Singing groups can support mothers with PND; however, online delivery has never been evaluated. SHAPER-PNDO, a single-arm clinical trial, evaluated the feasibility, clinical efficacy, and well-being outcomes of a 6-week online version of Breathe Melodies for Mums (M4M) singing intervention developed for mothers with PND during COVID-19 lockdowns., Methods: The primary objective of this study was to assess the feasibility of a group online singing intervention for new mothers with postnatal depression. This was ascertained through recruitment rates, study retention rates, attendance rates to the singing sessions, and study completion rates. The secondary objective of the study was to assess the clinical efficacy and well-being outcomes of the singing intervention. Specifically, we measured change in Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI), Perceived Stress Scale (PSS), and Office for National Statistics Wellbeing Scale (ONS) scores from baseline to end-of-intervention (week 6); follow-up assessments were completed at weeks 3, 16, and 32. Mothers were eligible if they scored ≥10 on the baseline EPDS., Results: Eighty-seven percent of the 37 recruited mothers completed the study, attending, on average, 5 of the 6 group singing sessions. With regard to secondary outcomes, at end-of-treatment, mothers experienced significant reductions in depression (EPDS, 16.6 ± 3.7 to 11.2 ± 5.3, 95% CI [0.79,1.65]), anxiety (STAI-S, 48.4 ± 27.1 to 41.7 ± 26.8, 95% CI [4.96, 17.65]) and stress (PSS, 29.0 ± 5.7 to 19.7 ± 5.3, 95% CI [1.33, 7.07]); and, furthermore, significant improvements in life satisfaction (ONS, 50.5 ± 23.0 to 72.8 ± 11.7, 95% CI [- 39.86, - 4.64]) and feelings of worthwhileness (ONS, 51.7 ± 30.4 to 78.6 ± 15.1, 95% CI [- 52.79, - 0.85]). Reduction on the EPDS correlated with a reduction on the BDI and the STAI-S and maternal childhood maltreatment was predictive of a smaller treatment response., Conclusions: M4M online was feasible to mothers who partook in the programme. Furthermore, M4M online supports the mental health and well-being of new mothers experiencing PND, especially when barriers to in-person treatment are present., Trial Registration: ClinicalTrials.gov NCT04857593 . Registered 22 April 2021, retrospectively registered., (© 2023. The Author(s).)

Background: Adults with a serious mental illness (SMI) are at greater risk of physical health morbidity and premature death than the general population, largely as a result of preventable physical health issues. Staff working in mental health services have a role to play in addressing these inequalities, but little is known about how they perceive their role and how this impacts on their practice. Understanding this better would enable services to improve their approach and support better health outcomes for SMI patients. A service evaluation was undertaken to investigate how physical healthcare is approached within adult community mental health teams (CMHTs) at a South London (UK) Mental Health Trust., Methods: This was a prospective, cross-sectional evaluation design. Interviews and focus groups were conducted with clinical staff, service users and carers (non-professional caregivers e.g., family or friends, of adults living with an SMI), to understand their experiences and to identify key barriers and facilitators to supporting physical healthcare support for adults with SMI. Thematic analysis was conducted to identify key themes which were classified into five main categories., Results: 50 participants took part in the study, 38 were clinical staff, eight were service users and four were carers. We found staff widely recognised the importance of supporting physical healthcare. However, there was variability in how staff approached physical healthcare in routine practice, and differences in how physical healthcare is experienced by service users and carers. Staff were keen to engage in changes to the way physical healthcare is delivered in CMHTs. However, they sought clearer guidance on their roles and responsibilities, and wanted to better understand the rationale for changes in community mental health practice, such as increased screening for physical healthcare. Service users and carers felt equally that the role of CMHTs in physical healthcare was unclear, which limited their ability to access it and understand the benefit for their overall care. Staff articulated gaps in leadership and training that impacted on their ability to implement the overall vision for physical healthcare within the Trust., Conclusion: Mental health staff recognise the role they play in supporting the physical health of adults living with SMI. This evaluation provides insight into common barriers and facilitators faced by staff, service users and carers when providing or accessing physical healthcare within adult CMHTs. These findings indicate a more comprehensive and better articulated approach to physical healthcare in mental health Trusts is needed to ensure service users and their carers understand what support is available and how to access it and to equip staff to provide and sustain that care in routine practice., Competing Interests: NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no conflicts of interest to declare. The author NS declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Tredget, Williams, McGrath, Sadler, Gaughran, Ang, Stepan, Cross, Tweed, Orlando, Sevdalis and the Integrating our Mental and Physical Healthcare Systems (IMPHS) Study Team.)

Background: Healthcare-based Independent Domestic Violence Advisors (hIDVA) are evidence-based programmes that provide emotional and practical support to service users experiencing domestic abuse. hIDVA programmes are found to improve health outcomes for service users and are increasingly delivered across a range of healthcare settings. However, it is unclear how hIDVA programmes are implemented across maternity services and the key facilitators and barriers to their implementation. The aim of this study was to identify; how many English National Health Service (NHS) Trusts with maternity services have a hIDVA programme; which departments within the Trust they operate in; what format, content, and variation in hIDVA programmes exist; and key facilitators and barriers of implementation in maternity services., Methods: A national survey of safeguarding midwives (Midwives whose role specifically tasks them to protect pregnant women from harm including physical, emotional, sexual and financial harm and neglect) within all maternity services across England; descriptive statistics were used to summarise responses. A World Café event (a participatory method, which aims to create a café atmosphere to facilitate informal conversation) with 38 national key stakeholders to examine barriers and facilitators to hIDVA programme implementation., Results: 86/124 Trusts (69%) with a maternity service responded to the survey; 59(69%) of respondents reported that they had a hIDVA programme, and 47(55%) of the hIDVA programmes operated within maternity services. Key facilitators to implementation of hIDVA programmes included training of NHS staff about the hIDVA role and regular communication between Trust staff and hIDVA staff; hIDVA staff working directly from the Trust; co-creation of hIDVA programmes with experts by experience; governance and middle- and senior-management support. Key barriers included hIDVA staff having a lack of access to a private space for their work, insecure funding for hIDVA programmes and issues with recruitment and retention of hIDVA staff., Conclusions: Despite hIDVA programmes role in improving the health outcomes of service users experiencing domestic abuse, increased funding and staff training is needed to successfully implement hIDVA staff in maternity services. Integrated Care Board commissioning of acute and mental health trust services would benefit from ensuring hIDVA programmes and clinician DVA training are prioritised., (© 2023. The Author(s).)

Background: Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems., Objectives: To assess the effects of case management for integrated care of older people living with frailty compared with usual care., Search Methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts., Selection Criteria: We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty., Data Collection and Analysis: We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence., Main Results: We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I 2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I 2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I 2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care., Authors' Conclusions: We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others., (Copyright © 2023 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.)

Introduction: In cancer care, multidisciplinary team (MDT) meetings are the gold standard. While they are trying to maximize productivity on the back of the steadily increasing workload, growing cancer incidence, financial constraints, and staff shortages, concerns have been raised with regards to the quality of team output, as reported by Cancer Research UK in 2017: " Sometimes we discuss up to 70 patients. This is after a whole day of clinics, and we do not finish until after 19.00. Would you want to be number 70? ". This study aimed to explore systematically some of the dynamics of group interaction and teamwork in MDT meetings., Materials and Methods: This was a prospective observational study conducted across three MDTs/university hospitals in the United Kingdom. We video-recorded 30 weekly meetings where 822 patient cases were reviewed. A cross-section of the recordings was transcribed using the Jefferson notation system and analyzed using frequency counts (quantitative) and some principles of conversation analysis (qualitative)., Results: We found that, across teams, surgeons were the most frequent initiators and responders of interactional sequences, speaking on average 47% of the time during case discussions. Cancer nurse specialists and coordinators were the least frequent initiators, with the former speaking 4% of the time and the latter speaking 1% of the time. We also found that the meetings had high levels of interactivity, with an initiator-responder ratio of 1:1.63, meaning that for every sequence of interactions initiated, the initiator received more than a single response. Lastly, we found that verbal dysfluencies (laughter, interruptions, and incomplete sentences) were more common in the second half of meetings, where a 45% increase in their frequency was observed., Discussion: Our findings highlight the importance of teamwork in planning MDT meetings, particularly with regard to Cancer Research UK in 2017 cognitive load/fatigue and decision-making, the hierarchy of clinical expertise, and the increased integration of patients' psychosocial information into MDT discussion and their perspectives. Utilizing a micro-level methodology, we highlight identifiable patterns of interaction among participants in MDT meetings and how these can be used to inform the optimization of teamwork., Competing Interests: BL and TS received funding from Cancer Alliance and Health Education England for training MDTs in assessment and quality improvement methods in the United Kingdom. TS received consultancy fees from Roche Diagnostics. NS is the Director of London Safety & Training Solutions Ltd., which provides patient safety and quality improvement training and advisory services on a consultancy basis to hospitals and training programs in the UK and internationally. JG is the Director of Green Cross Medical Ltd. that developed MDT FIT for use by National Health Service Cancer Teams in the UK. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Soukup, Lamb, Green, Sevdalis and Murtagh.)

Improved uptake of adult vaccinations could substantially reduce the burden of infectious disease worldwide, however very few countries achieve high coverage of recommended adult vaccinations. Vaccine hesitancy is an important driver of low vaccine uptake among adults but no measure currently exists to capture general vaccination attitudes in this population accurately and efficiently. We utilize data from two surveys of adult vaccine attitudes and uptake conducted in fifteen countries to evaluate the Vaccination Trust Indicator (VTI). The VTI is a six-item measure intended to capture general vaccine attitudes. We utilized multivariable logistic regression to examine the association between VTI scores and self-reported receipt of the seasonal influenza vaccine, receipt of a tetanus toxoid-containing vaccine and intent to receive the flu vaccine in the next season. In the five countries with self-reported vaccine receipt data, we found that a ten-point increase in VTI score was associated with a 50% increase in odds of influenza vaccine receipt (OR = 1.55, 95% CI = 1.48, 1.62) and 25% increase in the odds of tetanus vaccine receipt (OR = 1.26, 95% CI = 1.21, 1.30). Strong associations between VTI score and vaccine receipt were found in each country except China. A strong association between VTI score and intent to receive the influenza vaccine was found in all fifteen countries. The VTI is a promising tool for assessing adult immunization attitudes with clear and immediate uses for immunization programs globally., Competing Interests: I have read the journals policy and the authors of this manuscript have the following competing interests: NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organizations and the pharmaceutical industry. AT was an employee of Sanofi Pasteur when the original country survey was performed. He is Principal, Irimi Company, which offers consulting services in behavioral public health. MKE and SBO have no competing interests to declare., (Copyright: © 2023 Ellingson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Quality improvement (QI) in healthcare is a cultural transformation process. We explored how routine reporting could be developed to aid visibility of the process for QI governance., Method: A retrospective evaluation of QI projects in a large healthcare organisation was conducted. We used an online survey so that the data accrual process resembled routine reporting to help identify implementation challenges. A purposive sample of QI projects was targeted to maximise contrast between projects that were or were not successful as determined by the resident QI team. To hone strategic focus in what should be reported, we also compared factors that might affect project outcomes., Results: Out of 52 QI projects, 10 led to a change in routine practice ('adoption'). Details of project outcomes were limited. Project team outcomes, indicative of capacity building, were not systematically documented. Service user involvement, quality of measurement plan, fidelity of plan-do-study-act (PDSA) cycles had a major impact on adoption., Conclusion: Designing a routine reporting framework requires an iterative process to navigate data accrual demands. A retrospective evaluation, as in this study, can yield empirical insights to support development of QI governance, thereby honing the implementation science of QI in a healthcare organisation., Competing Interests: Competing interests NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no conflicts of interest to declare., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date., (© 2023 Association of Anaesthetists.)

Background: We investigated factors associated with COVID-19 vaccine uptake, future vaccination intentions, and changes in beliefs and attitudes over time., Methods: Prospective cohort study. 1500 participants completed an online survey in January 2021 (T1, start of vaccine rollout in the UK), of whom 1148 (response rate 76.5 %) completed another survey in October 2021 (T2, all UK adults offered two vaccine doses). Binary logistic regression analysis was used to investigate factors associated with subsequent vaccine uptake. Content analysis was used to investigate the main reasons behind future vaccine intentions (T2). Changes in beliefs and attitudes were investigated using analysis of variance., Findings: At T2, 90.0 % (95 % CI 88.2-91.7 %) of participants had received two doses of a COVID-19 vaccine, 2.2 % (95 % CI 1.3-3.0 %) had received one dose, and 7.4 % (95 % CI 5.9-8.9 %) had not been vaccinated. Uptake was associated with higher intention to be vaccinated at T1, greater perceived vaccination social norms, necessity of vaccination, and perceived safety of the vaccine. People who had initiated vaccination reported being likely to complete it, while those who had not yet received a vaccine reported being unlikely to be vaccinated in the future. At T2, participants perceived greater susceptibility to, but lower severity of, COVID-19 ( p  < 0.001) than at T1. Perceived safety and adequacy of vaccine information were higher ( p  < 0.001)., Interpretation: Targeting modifiable beliefs about the safety and effectiveness of vaccination may increase uptake., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organizations and the pharmaceutical industry. At the time of writing GJR is acting as an expert witness in an unrelated case involving a life sciences company, supported by LS. The other authors have no conflicts of interest to declare. LS, RA and GJR were participants of the Scientific Advisory Group for Emergencies or its subgroups., (© 2023 Published by Elsevier Ltd.)

Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker well-being. The implementation of human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. To encourage the adoption of human factors science in anaesthesia, the Difficult Airway Society and the Association of Anaesthetists established a Working Party, including anaesthetists and operating theatre team members with human factors expertise and/or interest, plus a human factors scientist, an industrial psychologist and an experimental psychologist/implementation scientist. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a 'hierarchy of controls' model and classified into design, barriers, mitigations and education and training strategies. Although most anaesthetic knowledge of human factors concerns non-technical skills, such as teamwork and communication, human factors is a broad-based scientific discipline with many other additional aspects that are just as important. Indeed, the human factors strategies most likely to have the greatest impact are those related to the design of safe working environments, equipment and systems. While our recommendations are primarily provided for anaesthetists and the teams they work with, there are likely to be lessons for others working in healthcare beyond the speciality of anaesthesia., (© 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Background: It is not well understood the overall changes that multidisciplinary teams (MDTs) have had to make in response to the COVID-19 pandemic, nor the impact that such changes, in addition to the other challenges faced by MDTs, have had on decision-making, communication, or participation in the context of MDT meetings specifically., Methods: This was a mixed method, prospective cross-sectional survey study taking place in the United Kingdom between September 2020 and August 2021., Results: The participants were 423 MDT members. Qualitative findings revealed hybrid working and possibility of virtual attendance as the change introduced because of COVID-19 that MDTs would like to maintain. However, IT-related issues, slower meetings, longer lists and delays were identified as common with improving of the IT infrastructure necessary going forward. In contrast, virtual meetings and increased attendance/availability of clinicians were highlighted as the positive outcomes resulting from the change. Quantitative findings showed significant improvement from before COVID-19 for MDT meeting organisation and logistics (M = 45, SD = 20) compared to the access (M = 50, SD = 12, t(390) = 5.028, p = 0.001), case discussions (M = 50, SD = 14, t(373) = -5.104, p = 0.001), and patient representation (M = 50, SD = 12, t(382) = -4.537, p = 0.001) at MDT meetings., Discussion: Our study explored the perception of change since COVID-19 among cancer MDTs using mixed methods. While hybrid working was preferred, challenges exist. Significant improvements in the meeting organisation and logistics were reported. Although we found no significant perceived worsening across the four domains investigated, there was an indication in this direction for the case discussions warranting further 'live' assessments of MDT meetings., (© 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: The World Health Organization's Global Patient Safety Action Plan 2021-2030 call for attention to patient and family involvement to reduce preventable patient harm. Existing evidence indicates that patients' involvement in their own safety has positive effects on reducing hospitalisation time and readmissions. One intervention reported in the literature is the use of checklists designed for patients' completion. Studies on such checklists are small scale, but they are linked to reduction in length of hospital stay and readmissions. We have previously developed and validated a two-part surgical patient safety checklist (PASC). This study aims to investigate the feasibility of the PASC usage and implementation prior to its use in a large-scale clinical trial., Methods: This is a prospective cross-sectional feasibility study, set up as part of the design of a larger stepped-wedge cluster randomised controlled trial (SW-CRCT). Descriptive statistics were used to investigate patient demographics, reasons for not completing the PASC and percentage of PASC item usage. Qualitative patient interviews were used to identify barriers and drivers for implementation. Interview was analysed through content analysis., Results: Out of 428 recruited patients, 50.2% (215/428) used both parts of PASC. A total of 24.1% (103/428) of the patients did not use it at all due to surgical or COVID-19-related cancellations. A total of 19.9% (85/428) did not consent to participate, 5.1% (22/428) lost the checklist and 0.7% (3/428) of the patients died during the study. A total of 86.5% (186/215) patients used ≥ 80% of the checklist items. Barriers and drivers for PASC implementation were grouped into the following categories: Time frame for completing the checklist, patient safety checklist design, impetus to communicate with healthcare professionals and support throughout the surgical pathway., Conclusions: Elective surgical patients were willing and able to use PASC. The study further revealed a set of barriers and drivers to the implementation. A large-scale definitive clinical-implementation hybrid trial is being launched to ascertain the clinical effectiveness and scalability of PASC in improving surgical patient safety., Trial Registration: Clinicaltrials.gov: NCT03105713. Registered 10.04.2017., (© 2023. The Author(s).)