Surgical site infections (SSIs), particularly intra-abdominal (IAB) infections, are challenging to identify and remain a resource-intensive focus of infection prevention programmes. Current automated screening measures rely on discrete data from the electronic health record (EHR), such as microbiology results, diagnosis codes and/or return to the operating room. This approach has poor specificity, and therefore surveillance methods depend heavily on additional manual chart review by trained infection preventionists. Large language models (LLMs) offer an opportunity to improve surveillance by synthesising complex clinical documentation alongside structured data elements.

We evaluated the performance of a locally hosted LLM (gpt-35-turbo-16k) to improve IAB SSI screening using perioperative clinical notes and microbiology results. The model analysed documentation across the perioperative period (3 days before through 30 days after surgery) to generate case-level SSI summaries and likelihood assessments. We compared the performance of this tool against the current EHR-based screening workflow.

Among 1977 abdominal surgical cases, including 56 with confirmed IAB SSIs, the LLM screened 104 cases as high risk, identifying all infections (negative predictive value (NPV) 100%) and achieving a positive predictive value (PPV) of 53.8%. In contrast, the EHR-based workflow identified 288 cases for further review, with a PPV of only 19.4% and the same NPV of 100%. Analysis of 57 224 notes required ~107 million tokens, translating to approximately USD 0.05 per case.

An LLM-based approach to SSI surveillance has the potential to substantially improve efficiency while remaining highly accurate and cost-effective. By reducing reliance on manual chart review, this strategy could allow infection preventionists to shift their attention from surveillance toward quality improvement and patient safety initiatives.

Introduction

The relationship between scientific evidence and clinical practice is almost universally described as a gap—a disconnect between the evidence that tells us what to do and what we actually do in practice. An oft-cited statistic is that it takes 17 years for evidence to change practice and entire fields like implementation science have emerged to address this gap.1

However, this is only one of the ways in which evidence and practice relate. In other situations, the problem is not a failure to integrate known evidence, but the absence of evidence altogether. Additionally, practice itself can be highly variable or highly uniform, whether guided by evidence or not. Each of these scenarios represents a distinct relationship between evidence and practice. As such, each requires a different approach to effectively improve care.

This Viewpoint argues that recognising the specific association between the conduct of clinical practice and...

"Errors must be accepted as evidence of systems flaws, not character flaws."—Lucian Leape1

In losing Lucian Leape to heart failure last 30 June, at the age of 94 years, we lost a rare physician whose insights fundamentally changed how clinicians and the public understand the practice of medicine. His contributions helped transform medicine’s moral self-conception from one that prized perfection and regarded error as a character failure to one that prizes humility and understanding failure. Medical mistakes were his laboratory. They were both his subject and his inspiration. And his career was a study in audacity and late blooming.

He was born on 7 November 1930, in Bellevue, Pennsylvania. His father worked for a steel company. His mother was a schoolteacher. He studied chemistry at Cornell, where he met his wife, Marty. He served in the US Navy, then went to Harvard Medical School, graduating in 1959....

At the Alma-Ata conference in 1978, multiple influential organisations gathered to define the core values of primary care.1 At this meeting, it was decided to adopt continuity of care as one of the core values. Continuity of care has several components: relational continuity, which stresses the personal patient–practitioner relationship over time; management continuity, which is about coordination of care across different healthcare professionals (HCPs); and informational continuity, which relates to appropriate transfer of patient data between different HCPs and between primary and secondary care.2

Numerous studies have shown beneficial effects of aiming for continuity of care. It is associated with reductions in emergency department use, hospital admissions and mortality.3–5 Importantly, it is also associated with improvements in patient satisfaction.6 7 Inversely, a reduction in continuity of care is associated with reduced patient satisfaction and higher...

Many patients with cancer are diagnosed in an emergency care context (often also termed ‘emergency presentation’ (EP)), and these patients have markedly worse prognosis and poorer patient experience even after adjustment for stage at diagnosis.1 2 Therefore, reducing the frequency of diagnosis of cancer as an emergency is an important public health and healthcare quality improvement target. Yet the extent to which preventing diagnosis as an emergency leads to improved survival remains unclear, and we do not know whether effective strategies to reduce the frequency of emergency diagnosis exist. Khalaf et al provide important new evidence to help address these critical questions.3

In 2012, Elliss-Brookes et al linked English cancer registration with National Health Service hospital administration and screening programme data to produce the first population-wide study examining the ‘routes to diagnosis’ of cancer.4 The findings were revealing. Across 15 common...

Objective

Relational continuity of care is associated with better patient experience and health outcomes. In England, relational continuity of primary care has been declining over a decade, coinciding with an increase in patient complaints. This study investigates the relationship between relational continuity of care and patient complaints.

Methods

Cross-sectional analysis of linked practice-level data in the English National Health Service (NHS) (2016/2017–2022/2023) obtained from NHS Digital and General Practice Patient Survey (GPPS). A negative binomial model was used to investigate the association between the proportion of patients never or almost never seeing their preferred general practitioner (GP) and new written complaints per 10 000 patients, with adjustment for patient demographics, socioeconomic status, care experiences, practice care capacity and care quality. Mediation analysis was further conducted to examine patients’ lost trust and unmet clinical needs as potential mechanisms.

Results

A 10 percentage point increase in the proportion of patients reporting low continuity was associated with 1.34 more new complaints per 10 000 patients (95% CI 1.23 to 1.46). The association may be stronger after than before the pandemic, among general practices with historically better continuity, and in more deprived areas. The findings were robust in using different measures of relational continuity, adjusting for primary case demand–supply mismatches, implementing a Poisson model with practice fixed effects and excluding ethnicity from the model specification. Mediation analysis showed that neither lost trust nor unmet care needs were important mediators of the effects of low continuity.

Conclusion

Self-reported low continuity of primary care is associated with more patient complaints in England. Future research should explore potential underlying mechanisms and establish whether the same relationship exists between objectively measured relational continuity and patient complaints.

Background

We previously developed a digital quality measure (dQM) of emergency presentations (EPs) in colorectal cancer (CRC) and found it to be associated with worse outcomes. Potentially avoidable EPs were common in this cohort, but identifying them required time-intensive chart reviews. We aimed to enhance the existing dQM to automate the detection of potentially avoidable EPs.

Materials and methods

We defined potentially avoidable EPs as those preceded by a CRC red flag (iron-deficiency anaemia or haematochezia ≥60 days prior, or positive stool-based screening test ≥180 days prior). The enhanced dQM was applied to a national cohort of incident CRC cases diagnosed in the Veterans Affairs healthcare system from 2017 to 2021. We examined associations with cancer stage, treatment and mortality.

Results

The enhanced dQM had a positive predictive value of 92% (95% CI 85.5% to 95.7%) for identifying potentially avoidable EPs. Among 9096 CRC cases, 28.1% were identified as EPs. Of these, 31.6% were classified as potentially avoidable. These patients were more likely to have advanced-stage disease (adjusted OR 1.50; 95% CI 1.27 to 1.78), less likely to receive treatment (adjusted OR 0.58; 95% CI 0.48 to 0.70) and had higher mortality (adjusted HR 1.58; 95% CI 1.40 to 1.79) compared with other patients with CRC.

Conclusions

The enhanced dQM accurately identified potentially avoidable EPs, which were associated with worse outcomes. This measure is unique in its focus on cases of preventable care delays, which can help guide future efforts to improve diagnostic timeliness and reduce EPs among patients with CRC.

Background

Voluntary assisted dying (VAD) in Victoria, Australia, is governed by a stringent legislative framework, designed and enforced by the state, as well as other forms of regulation. However, there remains limited understanding about how these various forms of regulation operate at the frontline or how clinicians themselves can influence regulation.

Objectives

This article explores how clinicians working at the frontline (clinical coalface) may influence the regulation of VAD in Victoria, and how this contributes to the safe and effective delivery of VAD.

Methods

Reflexive thematic analysis of 30 semistructured interviews with 37 ‘regulators’ (defined as those capable of steering and guiding behaviour with respect to VAD).

Results

Data analysis resulted in the generation of three main themes: (1) coalface regulation extends regulations at the clinical level, ensuring adherence to laws while developing new standards and systems for safe and effective practice; (2) coalface regulation guides day-to-day VAD practice; and (3) coalface regulation plays a critical role in quality monitoring and improvement.

Conclusions

Clinicians play a significant role in VAD regulation in Victoria and fulfil what we define as a ‘coalface regulator’ role. These coalface regulators are influential in ensuring the safe and effective delivery of VAD. Understanding how coalface regulation intersects with other forms of VAD regulation and how this regulatory influence can be harnessed is critical for optimising VAD regulation, safety and improving service delivery at a local and system level.

Objective

Quality improvement (QI) practices and scholarship are increasingly concerned with environmental sustainability given the negative health outcomes caused by the ecological crisis, as well as the environmental impacts of healthcare delivery itself. A core component of QI activities is measuring change. How sustainability metrics have been used in QI is unclear. We conducted a scoping review of metrics used in published sustainability-focused QI initiatives.

Data sources

MEDLINE, EMBASE, CINAHL and Scopus from 2000 to 2023.

Eligibility criteria

Published healthcare QI initiatives intended to address environmental sustainability with at least one quantitative sustainability metric.

Data analysis

Publication, study, measurement and QI intervention characteristics were charted from included studies. Data items were synthesised and presented narratively as well as quantitatively.

Results

We screened 6294 studies and included 90 full-text publications. The studies were published from 2000 to 2023, with the majority (61%, 55/90) published since 2020. Publications originated from a wide range of clinical disciplines with most QI projects situated in the inpatient setting (78%, 70/90). Environmental sustainability metrics were subcategorised into activity data and environmental impact indicators. Some papers included more than one category of activity data, with the most common being cost (88%, 79/90), hospital waste (52%, 47/90), anaesthetic gases (49%, 44/90), disposable use (24%, 22/90) and distance travelled (14%, 13/90). Fewer publications included environmental impact indicators, with global warming potential dominating this category (53%, 48/90).

Discussion

There is a need to align QI efforts with environmental sustainability. However, there is limited guidance specific to healthcare QI on how to measure environmental impacts of these efforts. This review illuminates that sustainability-focused QI efforts to date have used a relatively narrow set of sustainability metrics. QI scholars and practitioners can benefit from further education, measurement frameworks and guidelines to effectively incorporate environmental sustainability metrics into QI efforts.

Objectives

With the growing adoption of virtual consultations in primary care, the need for tailored metrics to evaluate their safety became increasingly urgent. This systematic review seeks to identify and review existing safety measures that could be used for safety evaluation of virtual consultations in primary care.

Methods

This has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and followed a published protocol. A systematic literature search was performed in Ovid MEDLINE/PubMed, Embase and Cochrane Library databases from 2014 to 2024. Studies comparing virtual consultations with face-to-face consultations in the primary care setting were included. An inductive thematic analysis was performed to systematically extract and group the safety measures into overarching themes, with a narrative synthesis to summarise the results.

Results

A total of 47 studies (31 experimental and 16 observational studies) were included (n=2 223 697 patients). All studies assessed the safety of virtual versus face-to-face consultations via one or both of the following domains: (1) factors that influence the safety of virtual consultations and (2) tangible outcomes of virtual care safety. The former were categorised into provider-related, patient-related and system-related factors. Tangible outcomes were evident through three subthemes—adverse events, health outcomes and patient perception of safety.

Conclusions

This review provides a systematic synthesis of measures for the safety evaluation of virtual consultations. Further research into patient and physician perspectives is needed to identify aspects and indicators not captured in this study, followed by a consensus study to finalise safety metrics. Ultimately, having a robust methodology for safety evaluation of virtual consultations in place will enable safety monitoring, root cause analyses and safety improvement.

PROSPERO registration number

PROSPERO CRD42023464878.

What if the biggest threat to sustainable improvement in healthcare is not failing to learn—but failing to forget?

Sustainability is not static maintenance; it is evolution. Health systems that can adapt, discard and relearn, retaining what matters and deliberately forgetting what no longer serves patients, can sustain high-value care and continually move beyond low-value practices.

When learning is not enough: why health systems must learn to forget

Healthcare prides itself on being a learning system. We collect data, consider the context, analyse outcomes and iterate improvement cycles. Yet, true sustainability—the ability to embed and maintain improvement over time—requires more than learning: it demands deliberate unlearning. Outdated order sets, decision rules and routines have the potential to shape care long after evidence has evolved.1 A paradox of improvement is that systems cannot sustain what is new until they have let go of what is old....

Patient safety huddles have been employed across healthcare settings to boost safety culture and improve patient outcomes. However, there is a dearth of literature pertaining to physicians’ levels of interest in participating in these huddles, as well as the impact of physician presence on patient care dynamics. Multidisciplinary huddles aimed at identifying and addressing patient safety issues related to the electronic health record (EHR), for example, were helpful for promoting discussion of EHR-related safety concerns.1 Furthermore, there is a robust literature demonstrating the patient safety benefits of perioperative time-outs in the surgical literature, as well as structured handoffs at the time of care transfer.2–5 Yet hospitalist physicians were not always routinely a key part of these huddles, even though representatives from the medical and surgical services were among the 40 roles that attended some huddles in these studies.

As people age, so do their kidneys.1 The average decline in renal function is approximately 1 mL/min/year after 30 years old.2 3 Over 40% of people >70 years meet the Kidney Disease Improving Global Outcomes definition of chronic kidney disease (CKD), reflecting the increased prevalence of this condition in older people.4 5 Renal function decline is further accelerated through conditions such as hypertension, atherosclerosis, diabetes and cardiovascular disease, which are common comorbidities in older people.6 Safe prescribing of medication for older people with reduced kidney function is an ongoing challenge. Reduced renal excretion of medications eliminated through the kidney exposes people to increased drug plasma levels and increases the risk of medication-related harm leading to adverse drug events, increased hospitalisations and increased mortality.1 7 The presence of polypharmacy, among other issues, in this age...

Background

In 2017, the PREDICT (Paediatric Research in Emergency Departments International Collaborative) network conducted a cluster randomised controlled trial (cRCT) at 26 Australian and New Zealand hospitals to improve bronchiolitis care. Findings demonstrated that targeted interventions significantly improved adherence with five evidence-based low-value bronchiolitis practices (no chest radiography, salbutamol, glucocorticoids, antibiotics and epinephrine) in the first 24 hours of hospitalisation (adjusted risk difference, 14.1%; 95% CI: 6.5% to 21.7%; p<0.001). During the intervention year (2017), intervention hospital (n=13) compliance was 85.1% (95% CI: 82.6% to 89.7%). This study aimed to determine if improvements in bronchiolitis management were sustained at intervention hospitals 2 years post-trial completion.

Methods

International, multicentre follow-up study of hospitals in Australia and New Zealand that participated in a cRCT of de-implementation of low-value bronchiolitis practices, 1 year (2018) and 2 years (2019) post-trial completion, obtained retrospectively from medical audits. Sustainability was defined a priori as no more than a <7% decrease to any level of improvement in adherence for all five low-value practices (composite outcome) from the cRCT intervention year.

Results

Of the 26 hospitals, 11 intervention and 10 control hospitals agreed to participate in the follow-up study. Data were collected on 3299 infants with bronchiolitis 1 year (intervention and control hospitals) and 1689 infants 2 years post-trial (intervention hospitals). Adherence with no use of the five low-value practices 2 years post-trial completion was 80.9% (adjusted predicted adherence, 80.8%, 95% CI: 77.4% to 84.2%; estimated risk difference from cRCT outcome –3.9%, 95% CI: –8.6% to 0.8%) at intervention hospitals, fulfilling the a priori definition of sustainability.

Discussion

Targeted interventions, delivered over one bronchiolitis season, resulted in sustained improvements in bronchiolitis management in infants 2 years later. This follow-up study provides evidence for sustainability in de-implementing low-value care in bronchiolitis management.

Trial registration details

Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

Background

The 2017 Paediatric Research in Emergency Departments International Collaborative (PREDICT) Bronchiolitis Knowledge Translation (KT) Study, a cluster randomised trial in 26 Australasian hospitals, found targeted interventions provided over one bronchiolitis season effectively de-implemented five low-value practices (salbutamol, glucocorticoids, chest radiography, antibiotics and epinephrine) by 14.1% (adjusted risk difference, 95% CI 6.5% to 21.7%; p<0.001). A 2-year follow-up study found de-implementation was sustained. This process evaluation aimed to identify factors that influenced sustainability of de-implementation of these five low-value practices in PREDICT Bronchiolitis KT Study intervention hospitals and examine fidelity and/or adaptation of the targeted interventions over 4 years post intervention delivery (sustainment).

Methods

Semistructured qualitative interviews were conducted, over 2021 and 2022, with a purposive sample of emergency department (ED) and paediatric inpatient clinicians. Data were analysed thematically into facilitators and barriers using the Consolidated Framework for Sustainability Constructs in Healthcare (CFSCH). The Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies was used to explore fidelity and adaptation.

Results

50 clinicians (nurses: n=26; doctors: n=24) from 12 intervention hospitals were interviewed. Eight themes were identified and mapped to three CFSCH domains: (1) organisational setting; (2) initiative design and delivery and (3) people involved. Facilitators were a culture of evidence-based practice, ongoing multimodal education, strong clinical leadership as unofficial champions and the previous effectiveness of the PREDICT Bronchiolitis KT Study interventions. Barriers were lack of paediatric trained ED staff, assumptions by senior clinicians that junior doctors can provide evidence-based bronchiolitis management, bronchiolitis not a current improvement priority and lack of bronchiolitis education sessions. Use of the targeted interventions reduced over time and, when used, was adapted locally.

Conclusion

This study provides insights into factors influencing the sustainability of de-implementation of low-value care in acute care settings. Fostering an evidence-based practice culture, supported by senior leadership and ongoing multimodal education, supports sustainability of improvements in this setting.

Trial registration number

Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

Background

Medical safety huddles are short, structured meetings for physicians to proactively discuss and respond to profession-specific patient safety concerns, with the goal of decreasing future adverse events. Prior observational studies found associations with improved patient safety outcomes, but no randomised controlled studies have been conducted.

Objective

The primary objective was to determine the impact of medical safety huddles on adverse events. Secondary objectives included the fidelity of huddle implementation and the impact on patient safety culture among physicians.

Design

Stepped-wedge cluster randomised trial with four sequences, and each hospital site was a cluster.

Setting

Inpatient oncology, surgery and rehabilitation programmes in four academic hospitals.

Participants

Physicians in participating programmes.

Intervention

Medical safety huddles were adapted for local context and implemented sequentially based on a computer-generated random sequence every 2 months after a 4-month control period. All sites remained in the intervention phase for at least 9 months.

Main outcome and measures

The primary outcome was the rate of adverse events, as determined through blinded chart audits of 912 randomly selected patients. The fidelity of implementation was assessed through the huddle attendance rate, number of safety issues raised in the huddles and number of actions taken in response. Patient safety culture was assessed using the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety.

Results

The adjusted rate of adverse events (per 1000 patient days) in the postintervention phase was 12% lower compared with preintervention (RR: 0.88; 95% CI: 0.80 to 0.98; p=0.016). The odds of having adverse events posthuddle implementation were 17% lower in the postintervention period compared with preintervention (OR intervention vs control: 0.83; 95% CI: 0.80 to 0.87; p<0.001). The mean huddle attendance rate at each site ranged from 30% to 85%, and the mean number of issues raised per huddle and the mean number of actions taken per huddle ranged from 1.6 to 3.1. The mean (SD) overall patient safety rating increased from 2.3 (0.53) to 2.8 (0.88), p=0.010. The mean per cent (SD) positive score for the composite measures of ‘Organisational learning’ increased significantly from 35% (26%) to 54% (23%), p=0.00, ‘Response to error’ 37% (24%) to 52% (22%), p=0.025 and ‘Communication about error’ 36% (28%) to 64% (42%), p=0.016 after implementation.

Conclusions and relevance

Medical safety huddles decreased adverse events and may improve patient safety culture through engaging physicians.

Trial registration number

NCT05365516.

Objectives

To capture experiences of people self-reporting harm and contrast responses and actions between those who do or do not take formal action.

Design

Semi-structured qualitative interview study.

Setting

People self-reporting harm experienced in the National Health Service (NHS) or their family/friends identified from a general Great British population survey.

Participants

49 participants.

Results

There were commonalities in experiences after harm whether formal action (including making a formal complaint or litigation) was taken or not. Many participants reported raising concerns informally with NHS staff, trying to access explanations or support, but were usually unsuccessful. Decision-making on action was complex. There were multiple reasons for not pursuing formal action, including fears of damaging relationships with clinicians, being occupied coping with the consequences of the harm or not wanting to take action against the NHS. NHS advocacy services were not regarded as helpful. Knowledge of how to proceed and feeling entitled to do so, along with proactive social networks, could facilitate action, but often only after people were spurred on by anger and frustration about not receiving an explanation, apology or support for recovery from the NHS. Those from marginalised groups were more likely to feel disempowered to act or be discouraged by family or social contacts, which could lead to self-distancing and reduced trust in services.

Conclusions

People actively seek resolution and recovery after harm but often face multiple barriers in having their needs for explanations, apologies and support addressed. Open and compassionate engagement, especially with those from more marginalised communities, plus tailored support to address needs, could promote recovery, decrease compounded harm and reduce use of grievance services where other provision may be more helpful.

Background

Increasing age is associated with reductions in kidney function and increasing polypharmacy. Most medicines are eliminated through the kidney, meaning older patients are at risk of medication accumulation and toxicity. This scoping review synthesised: (1) the prevalence at which older patients with reduced kidney function in primary care are exposed to inappropriate prescribing; (2) its associated harms; (3) the reasons for this occurring; and (4) the interventions used to improve prescribing practices.

Methods

This scoping review searched ‘Medline’, ‘Embase’, ‘PsycINFO’, ‘CINAHL’ and ‘Web of Science’ for publications before October 2024. References were managed on EndNote V.X5 and thematic data analysis was undertaken on Microsoft Excel. Common themes were identified, summary statistics were calculated and insights were summarised through a narrative technique.

Results

43 relevant studies explored the scale of inappropriate prescribing, estimating prevalences of patient exposure ranging from 0.6% to 49.1% (median 24.9%). Five studies explored the associated harm from inappropriate prescribing, but only one study assessed harm as a primary outcome. Eight studies that assessed difficulties in following prescribing guidelines in reduced kidney function suggested that a lack of awareness and trusted guidelines are fundamental problems. While 13 studies evaluated interventions for improving prescribing in reduced kidney function, only two demonstrated evidence of effectiveness and only one intervention was theoretically informed.

Conclusions

Despite significant heterogeneity in study characteristics, it is clear that the prevalence of inappropriate prescribing for older people is uncomfortably high. There is a lack of evidence linking this to associated adverse outcomes, as well as identifying the causative issues driving this behaviour and the preventative interventions that could prevent harm.

I have heard faculty members complain, on occasion, that students develop bad habits at these clinics because of inadequate supervision. Certainly the quality of care and the ethics of students ‘practicing’ on those who cannot afford other care should be reviewed.

-E. Poulsen, JAMA (1995)1

Introduction

Student-run clinics (SRCs), in which medical and health professions students take responsibility for operational and logistics management of charitable clinics,2 are a powerful expression of service-based learning: students hone clinical and administrative skills while communities receive essential medical services that might otherwise be unavailable. Yet over the past 20 years, these clinics have begun globalising2–5 and increasing in complexity.5 This is happening within a landscape of limited evidence,5 6 growing concerns about ethics and substandard care,7–13

Healthcare contributes nearly 5% of global greenhouse gas (GHG) emissions, along with significant waste, air pollution and water use.1 The production, transport and use of pharmaceuticals, chemicals, medical devices and medical supplies, as well as testing and procedures involved with healthcare delivery, carry a substantial environmental footprint.2 Given that climate change is the defining health challenge of this century, health systems have a moral and professional responsibility not only to provide high-quality care and ensure the best possible patient outcomes but also to minimise environmental harm and protect future generations. Environmentally sustainable healthcare is consistent with high-quality care, especially when framed in terms of stewardship,3 reducing low-value care and waste and improving efficiency and resilience. Additionally, interventions to achieve sustainable healthcare and reduce pollution must ensure that high-quality care is maintained. The study by Spoyalo et al4 is a fine example...