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Systems analysis of clinical incidents: development of a new edition of the London Protocol.
The investigation of incidents and accidents, together with subsequent reflection and action, is an essential component of safety management in every safety-critical industry, including healthcare. A number of formal methods of incident analysis were developed in the early days of risk management and patient safety, including the London Protocol which was published in 2004. In this paper, we describe the development of a new edition of the London Protocol. We explain the need for a revised and expanded version of the London Protocol, addressing both the changes in healthcare in the last two decades and what has been learnt from the experience of incident analysis across the world. We describe a systematic process of development of the new edition drawing on the findings of a narrative review of incident analysis methods. The principal changes in the new edition are as follows: increased emphasis and guidance on the engagement of patients and families as partners in the investigation; giving more attention to the support of patients, families and staff in the aftermath of an incident; emphasising the value of a small number of in-depth analyses combined with thematic reviews of wider problems; including proposals and guidance for the examination of much longer time periods; emphasising the need to highlight good care as well as problems; adding guidance on direct observation of the work environment; providing a more structured and wide-ranging approach to recommendations and including more guidance on how to write safety incident reports. Finally, we offer some proposals to place research on incident analysis on a firmer foundation and make suggestions for the practice and implementation of incident investigation within safety management systems.
Staff experience of a new approach to family safeguarding in Oxfordshire Children's Social Care Services
This paper presents the findings from a qualitative study that sought to understand the experiences of frontline staff working in Oxfordshire County Council (OCC) Children's Social Care Services and their views on a new family safeguarding model (Family Solutions Plus). Focus group interviews were conducted with 20 frontline staff and managers in different teams across OCC Children's Social Care Services using video conferencing software. Thematic analysis identified three overarching themes: Preparation for the implementation of Family Solutions Plus, staff views on the implemented model, and challenges to its implementation. Staff voiced strong support for the new model, which places a much greater emphasis than previous practice on supporting the whole family, developing parenting skills and keeping children safe with their families. The challenges associated with the transition to a new model were considerable in the short term, partly due to the COVID-19 pandemic, but there was optimism that the new model could be sustained and stabilized over time.
The common sense model in Raynaud's phenomenon: do illness perceptions account for variance in symptom severity and quality of life?
People with Raynaud’s phenomenon (RP) experience poorer mental health and quality of life than the general population, and there is limited evidence for treatment options in RP. The Common Sense Model of illness representations (CSM) is a well-established theoretical model, which has not yet been robustly investigated in RP, but may provide potential avenues for psychological interventions with the ability to explore perceptions and beliefs, such as cognitive behavioural therapy (CBT). The study aims were to investigate illness perceptions and examine the relationship between illness perceptions and symptom severity and quality of life in RP to explore a theoretical basis for potential treatment avenues. A cross-sectional online questionnaire design was employed and 169 adults with RP (primary or secondary) were analysed. Illness perceptions significantly differed between primary and secondary RP types on all but one domain (p < .05). Hierarchical multiple regressions indicated that illness perception subscales made a significant unique contribution to the models explaining 65% variance in symptom severity (R2 = .65, p < .001) and 30% variance in quality of life (R2 = .30, p < .001). This novel study provides preliminary evidence regarding the applicability of the CSM to RP in a clinically meaningful way. CBT, which can specifically target illness perceptions within a wider psychological formulation, may be helpful for individuals with RP who are experiencing psychological distress in relation to symptom severity. Further work is needed to develop outcome measures specific to RP and tailor interventions to manage distress and impaired quality of life.
Adaptive strategies used by surgical teams under pressure: an interview study among senior healthcare professionals in four major hospitals in the United Kingdom.
BACKGROUND: Healthcare systems are operating under substantial pressures, and often simply cannot provide the standard of care they aspire to within the available resources. Organisations, managers, and individual clinicians make constant adaptations in response to these pressures, which are typically improvised, highly variable and not coordinated across clinical teams. The purpose of this study was to identify and describe the types of everyday pressures experienced by surgical teams and the adaptive strategies they use to respond to these pressures. METHODS: We conducted interviews with 20 senior multidisciplinary healthcare professionals from surgical teams in four major hospitals in the United Kingdom. The interviews explored the types of everyday pressures staff were experiencing, the strategies they use to adapt, and how these strategies might be taught to others. RESULTS: The primary pressures described by senior clinicians in surgery were increased numbers and complexity of patients alongside shortages in staff, theatre space and post-surgical beds. These pressures led to more difficult working conditions (e.g. high workloads) and problems with system functioning such as patient flow and cancellation of lists. Strategies for responding to these pressures were categorised into increasing or flexing resources, controlling and prioritising patient demand and strategies for managing the workload (scheduling for efficiency, communication and coordination, leadership, and teamwork strategies). CONCLUSIONS: Teams are deploying a range of strategies and making adaptations to the way care is delivered. These findings could be used as the basis for training programmes for surgical teams to develop coordinated strategies for adapting under pressure and to assess the impact of different combinations of strategies on patient safety and surgical outcomes.
Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies.
OBJECTIVE: The objective of this review was to develop a taxonomy of pressures experienced by health services and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies were developed from a review of observational studies directly assessing care delivered in a variety of clinical environments. DESIGN: In the first phase, a scoping review of the relevant literature was conducted. In the second phase, pressures and strategies were systematically coded from the included papers, and categorised. DATA SOURCES: Electronic databases (MEDLINE, Embase, CINAHL, PsycInfo and Scopus) and reference lists from recent reviews of the resilient healthcare literature. ELIGIBILITY CRITERIA: Studies were included from the resilient healthcare literature, which used descriptive methodologies to directly assess a clinical environment. The studies were required to contain strategies for managing under pressure. RESULTS: 5402 potential articles were identified with 17 papers meeting the inclusion criteria. The principal source of pressure described in the studies was the demand for care exceeding capacity (ie, the resources available), which in turn led to difficult working conditions and problems with system functioning. Strategies for responding to pressures were categorised into anticipatory and on-the-day adaptations. Anticipatory strategies included strategies for increasing resources, controlling demand and plans for managing the workload (efficiency strategies, forward planning, monitoring and co-ordination strategies and staff support initiatives). On-the-day adaptations were categorised into: flexing the use of existing resources, prioritising demand and adapting ways of working (leadership, teamwork and communication strategies). CONCLUSIONS: The review has culminated in an empirically based taxonomy of pressures and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies could help clinicians and managers to optimise how they respond to pressures and may be used as the basis for training programmes and future research evaluating the impact of different strategies.
Correcting statistical misinformation about scientific findings in the media: Causation versus correlation.
Although retractions significantly reduce the number of references people make to misinformation, retracted information nevertheless persists in memory, continuing to influence reasoning. One hundred and twenty-nine lay participants completed an adaptation on the traditional continued influence paradigm, which set out to identify whether it is possible to debunk a piece of common statistical misinformation: inappropriate causal inference based on a correlation. We hypothesized that participants in the correction condition would make fewer causal inferences (misinformation) and more correlational inferences (correction) than those in the no-correction condition. Additional secondary hypotheses were that the number of references made to the misinformation and correction would be moderated by the level of trust in science and scientists, and the amount of television that participants watch. Although the secondary hypotheses were not supported, the data strongly supported the primary hypotheses. This study provides evidence for the efficacy of corrections about misinformation where correlational evidence has been inappropriately reported as causal. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
Psychological factors in symptom severity and quality of life in Raynaud's phenomenon.
BACKGROUND: Despite emotional stress being recognised as a key trigger for Raynaud's phenomenon episodes, research in the area is still in its infancy. AIMS: This study investigated the role of psychological factors relating to symptom severity and quality of life, and differences between Raynaud's types (primary and secondary) to further inform the development of intervention in this field. METHOD: A cross-sectional design was used. Two hundred and ten adults with Raynaud's completed an online questionnaire measuring stress, anxiety, depression, anxiety sensitivity, beliefs about emotions, symptom severity and quality of life. RESULTS: Primary and secondary Raynaud's groups differed in anxiety (p < .004), symptom severity (p < .001) and quality of life (p < .001). Stepwise multiple regressions indicated anxiety and Raynaud's type explained 23% variance in hand symptom severity (p < .001); anxiety, Raynaud's type and anxiety sensitivity explained 29% variance in symptom severity (global impact, p < .001); depression, Raynaud's type and anxiety sensitivity explained 32% variance in quality of life (p < .001). CONCLUSIONS: Results highlight the importance of psychological factors in Raynaud's phenomenon, indicating possible targets for treatment. Interventions such as cognitive behavioural therapy, which target both physical and psychological wellbeing, bear some promise as an adjuvant therapy for this group.
Strategies for adapting under pressure: an interview study in intensive care units.
BACKGROUND: Healthcare systems are operating under substantial pressures. Clinicians and managers are constantly having to make adaptations, which are typically improvised, highly variable and not coordinated across teams. This study aimed to identify and describe the types of everyday pressures in intensive care and the adaptive strategies staff use to respond, with the longer-term aim of developing practical and coordinated strategies for managing under pressure. METHODS: We conducted qualitative semi-structured interviews with 20 senior multidisciplinary healthcare professionals from intensive care units (ICUs) in 4 major hospitals in the UK. The interviews explored the everyday pressures faced by intensive care staff and the strategies they use to adapt. A thematic template analysis approach was used to analyse the data based on our previously empirically developed taxonomy of pressures and strategies. RESULTS: The principal source of pressure described was a shortage of staff with the necessary skills and experience to care for the increased numbers and complexity of patients which, in turn, increased staff workload and reduced patient flow. Strategies were categorised into anticipatory (in advance of anticipated pressures) and on the day. The dynamic and unpredictable demands on ICUs meant that strategies were mostly deployed on the day, most commonly by flexing staff, prioritisation of patients and tasks and increasing modes of communication and support. CONCLUSIONS: ICU staff use a wide variety of adaptive strategies at times of pressure to minimise risk and maintain a reasonable standard of care for patients. These findings provide the foundation for a portfolio of strategies, which can be flexibly employed when under pressure. There is considerable potential for training clinical leaders and teams in the effective use of adaptive strategies.
Reporting guideline for the use of Generative Artificial intelligence tools in MEdical Research: The GAMER Statement
Objectives: Generative artificial intelligence (GAI) tools can enhance the quality and efficiency of medical research, but their improper use may result in plagiarism, academic fraud and unreliable findings. Transparent reporting of GAI use is essential, yet existing guidelines from journals and institutions are inconsistent, with no standardised principles. Design and setting: International online Delphi study. Participants: International experts in medicine and artificial intelligence. Main outcome measures: The primary outcome measure is the consensus level of the Delphi expert panel on the items of inclusion criteria for GAMER (Rreporting guideline for the use of Generative Artificial intelligence tools in MEdical Research). Results: The development process included a scoping review, two Delphi rounds and virtual meetings. 51 experts from 26 countries participated in the process (44 in the Delphi survey). The final checklist comprises nine reporting items: general declaration, GAI tool specifications, prompting techniques, tool's role in the study, declaration of new GAI model(s) developed, artificial intelligence-assisted sections in the manuscript, content verification, data privacy and impact on conclusions. Conclusion: GAMER provides universal and standardised guideline for GAI use in medical research, ensuring transparency, integrity and quality.
Preferences for fat, sugar, and oral-sensory food qualities in monkeys and humans.
In humans and other primates, food intake depends on sophisticated, individualized preferences for nutrients and oral-sensory food qualities that guide decision-making and eating behavior. The neural and behavioral mechanisms for such primate-typical food preferences remain poorly understood, despite their importance for human health and their targeting by pharmacological obesity treatments. Here, we review a series of experiments that investigated how the biologically critical properties of foods-their nutrients (sugar, fat, protein) and oral-sensory qualities (viscosity, oral sliding friction)-influence food preferences in monkeys and humans. In an economic nutrient-choice paradigm, macaques flexibly trade nutrients and oral-sensory food qualities against varying food amounts, consistent with the assignment of subjective values. Nutrient-value functions that link objective nutrient content to subjective values accurately model these preferences, predict choices across contexts, and explain individual differences. The monkeys' aggregated choice patterns resulting from their nutrient preferences lead to daily nutrient balances that deviate from dietary reference points, resembling suboptimal human eating patterns when exposed to high-calorie foods. To investigate the sensory basis underlying nutrient values, we developed novel engineering tools that quantify food textures on oral surfaces, using fresh pig tongues. Oral-texture (i.e., mouthfeel) parameters, including viscosity and sliding friction, were shown to mediate monkeys' preferences for high-fat foods. When translated to human subjects, this approach revealed a neural mechanism for preferring high-fat foods from oral texture in the orbitofrontal cortex (OFC)-a key reward system of the brain. Importantly, human OFC responses to oral sliding friction in individual subjects-measured in the MRI scanner-predicted subsequent fat intake in a naturalistic, life-like eating test. These findings suggest that a primate nutrient-reward paradigm offers a promising approach for investigating the behavioral and neural mechanisms for human-typical food reward and food choice, to advance understanding of human eating behavior, overeating, and obesity.
Neocortical and Hippocampal Theta Oscillations Track Audiovisual Integration and Replay of Speech Memories.
"Are you talkin' to me?!" If you ever watched the masterpiece "Taxi Driver" directed by Martin Scorsese, you certainly recall the monologue during which Travis Bickle rehearses an imaginary confrontation in front of a mirror. While remembering this scene, you recollect a myriad of speech features across visual and auditory senses with a smooth sensation of unified memory. The aim of this study was to investigate how the fine-grained synchrony between coinciding visual and auditory features impacts brain oscillations when forming multisensory speech memories. We developed a memory task presenting participants with short synchronous or asynchronous movie clips focused on the face of speakers in real interviews, all the while undergoing magnetoencephalography recording. In the synchronous condition, the natural alignment between visual and auditory onsets was kept intact. In the asynchronous condition, auditory onsets were delayed to present lip movements and speech sounds in antiphase specifically with respect to the theta oscillation synchronizing them in the original movie. Our results first showed that theta oscillations in the neocortex and hippocampus were modulated by the level of synchrony between lip movements and syllables during audiovisual speech perception. Second, theta asynchrony between the lip movements and auditory envelope during audiovisual speech perception reduced the accuracy of subsequent theta oscillation reinstatement during memory recollection. We conclude that neural theta oscillations play a pivotal role in both audiovisual integration and memory replay of speech.
Exploring creaminess perception in ice cream products using a combined static and dynamic sensory approach
Background, Context, or Rationale: Creaminess is a critical determinant of the consumer acceptance of ice cream, yet its multidimensional sensory drivers—particularly across static and temporal dimensions—remain poorly characterised, thus hindering the development of healthier, low-fat alternatives. Aim(s): To identify key textural and temporal attributes governing creaminess perception in ice cream using complementary static (quantitative descriptive analysis, QDA) and dynamic (temporal check-all-that-apply, TCATA) sensory methodologies. Methods: A mixed-method framework was implemented: (1) A word association task with 186 consumers captured spontaneous creaminess descriptors, consolidated into 12 attributes via focus groups; (2) QDA quantified static correlations between creaminess and sensory properties; and (3) TCATA tracked dynamic attribute interactions over 60 s. Major Findings: Static drivers (QDA): Creaminess correlated negatively with melting time, coldness, hardness and iciness (P < 0.05), and positively with thickness and mouth coating (P < 0.05). Temporal dynamics (TCATA): Creaminess perception evolved in two phases: (1) 0–25 s: Driven by viscosity and mouth coating intensity (P < 0.05); (2) 60–120 s: Sustained by thickness and smoothness, delaying perceptual decline. Scientific or Industrial Implications: This dual-axis model advances creaminess characterisation by linking instantaneous texture (thickness and mouth coating) to time-dependent sensory transitions, offering a novel framework for studying complex sensory attributes. Findings enable targeted reformulation of low-fat ice creams by modulating thickness and smoothness in order to mimic fat-derived creaminess.
Active information sampling in health and disease
Active information gathering is a fundamental cognitive process that enables organisms to navigate uncertainty and make adaptive decisions. Here we synthesise current knowledge on the behavioural, neural, and computational mechanisms underlying information sampling in healthy people and across several brain disorders. The role of cortical and subcortical regions spanning limbic, insular, fronto-parietal, and striatal systems is considered, along with the contributions of key neurotransmitters involving norepinephrine, dopamine, and serotonin. We also examine how various clinical conditions, including schizophrenia, obsessive-compulsive disorder, and Parkinson's disease have an impact on information gathering behaviours. To account for the findings, we outline a neuroeconomic perspective on how the brain may evaluate the costs and benefits of acquiring information to resolve uncertainty. This work highlights how active information gathering is a crucial brain process for adaptive behaviour in healthy individuals and how its breakdown is relevant to several psychiatric and neurological conditions. The findings have important implications for developing novel computational assays as well as targeted interventions in brain disorders.