BACKGROUND: Electronic health record (EHR) transitions are known to be highly disruptive, can drastically impact clinician and staff experiences, and may influence patients\' experiences using the electronic patient portal. Clinicians and staff can gain insights into patient experiences and be influenced by what they see and hear from patients. Through the lens of an emergency preparedness framework, we examined clinician and staff reactions to and perceptions of their patients\' experiences with the portal during an EHR transition at the Department of Veterans Affairs (VA).
METHODS: This qualitative case study was situated within a larger multi-methods evaluation of the EHR transition. We conducted a total of 122 interviews with 30 clinicians and staff across disciplines at the initial VA EHR transition site before, immediately after, and up to 12 months after go-live (September 2020-November 2021). Interview transcripts were coded using a priori and emergent codes. The coded text segments relevant to patient experience and clinician interactions with patients were extracted and analyzed to identify themes. For each theme, recommendations were defined based on each stage of an emergency preparedness framework (mitigate, prepare, respond, recover).
RESULTS: In post-go-live interviews participants expressed concerns about the reliability of communicating with their patients via secure messaging within the new EHR portal. Participants felt ill-equipped to field patients\' questions and frustrations navigating the new portal. Participants learned that patients experienced difficulties learning to use and accessing the portal; when unsuccessful, some had difficulties obtaining medication refills via the portal and used the call center as an alternative. However, long telephone wait times provoked patients to walk into the clinic for care, often frustrated and without an appointment. Patients needing increased in-person attention heightened participants\' daily workload and their concern for patients\' well-being. Recommendations for each theme fit within a stage of the emergency preparedness framework.
CONCLUSIONS: Application of an emergency preparedness framework to EHR transitions could help address the concerns raised by the participants, (1) mitigating disruptions by identifying at-risk patients before the transition, (2) preparing end-users by disseminating patient-centered informational resources, (3) responding by building capacity for disrupted services, and (4) recovering by monitoring integrity of the new portal function.

BACKGROUND: Harm from medications is a major patient safety challenge among older persons. Adverse drug events tend to arise when prescribing or evaluating medications; therefore, interventions targeting these may promote patient safety. Guidelines highlight the value of a joint plan for continued treatment. If such a plan includes medications, a medication plan promoting patient safety is advised. There is growing evidence for the benefits of including patients and health care professionals in initiatives for improving health care products and services through co-design.
OBJECTIVE: This study aimed to identify participants\' needs and requirements for a medication plan and explore their reasoning for different design choices.
METHODS: Using a case study design, we collected and analyzed qualitative and quantitative data and compared them side by side. We explored the needs and requirements for a medication plan expressed by 14 participants (older persons, nurses, and physicians) during a co-design initiative in a regional health system in Sweden. We performed a directed content analysis of qualitative data gathered from co-design sessions and interviews. Descriptive statistics were used to analyze the quantitative data from survey answers.
RESULTS: A medication plan must provide an added everyday value related to safety, effort, and engagement. The physicians addressed challenges in setting aside time to apply a medication plan, whereas the older persons raised the potential for increased patient involvement. According to the participants, a medication plan needs to support communication, continuity, and interaction. The nurses specifically addressed the need for a plan that was easy to gain an overview of. Important function requirements included providing instant access, automation, and attention. Content requirements included providing detailed information about the medication treatment. Having the plan linked to the medication list and instantly obtainable information was also requested.
CONCLUSIONS: After discussing the needs and requirements for a medication plan, the participants agreed on an iteratively developed medication plan prototype linked to the medication list within the existing electronic health record. According to the participants, the medication plan prototype may promote patient safety and enable patient engagement, but concerns were raised about its use in daily clinical practice. The last step in the co-design framework is testing the intervention to explore how it works and connects with users. Therefore, testing the medication plan prototype in clinical practice would be a future step.

UNASSIGNED: This study examined the association between patient experience (PX, events experienced by patients during primary care that are an indicator of patient-centered quality) of primary care and varicella-zoster virus (VZV) vaccine uptake in older adults.
UNASSIGNED: A case-control study of VZV vaccination was conducted at a community hospital in Ibaraki, Japan. Patients aged 65 years or older who had continuously been patients of the hospital between April 2018 and April 2021 were included in the study. The vaccinated group consisted of 166 VZV-vaccinated patients. The controls consisted of 29 age- and sex-matched patients who did not receive VZV vaccination. A self-administered questionnaire was distributed between August and September 2021. It included the Japanese version of the Primary Care Assessment Tool Short Form (JPCAT-SF) to evaluate PX and included questions about recommendations for VZV vaccination by a physician and the vaccination history of relatives. Multivariable and intermediate factor analyses were used to assess whether there was an association between VZV vaccination and PX.
UNASSIGNED: Questionnaires were sent to 457 subjects. Responses from 228 (116 in the vaccination group and 112 in the non-vaccinated group) were included in the analysis. Multivariable analysis, which excluded physician recommendation for VZV vaccination as a variable because it was an intermediate factor in the analysis, showed an association between PX and VZV vaccination (odds ratio, 1.38; 95% confidence interval, 1.00-1.92; P = .049).
UNASSIGNED: PX was associated with past VZV vaccination. Physician recommendation for VZV vaccination was an intermediate factor between PX and VZV vaccination.

BACKGROUND: Workplace violence against medical staff in China is a widespread problem that has negative impacts on medical service delivery. The study aimed to contribute to the prevention of workplace violence against medical staff in China by identifying patterns of workplace violence, key risk factors, and the interplay of risk factors that result in workplace violence.
METHODS: Ninety-seven publicly reported Chinese healthcare violent incidents from late 2013 to 2017 were retrospectively collected from the internet and analysed using content analysis. A modified socio-ecological model guided analysis of the violent incidents focusing on risk.
RESULTS: Physical violence, yinao, or a combination of physical and verbal violence were the typical forms of violence reported. The findings identified risk at all levels. Individual level risk factors included service users\' unreasonable expectations, limited health literacy, mistrust towards medical staff, and inadequacy of medical staff\'s communication during the medical encounter. Organisational level risk factors under the purview of hospital management included problems with job design and service provision system, inadequacies with environmental design, security measures, and violence response mechanisms within hospitals. Societal level risk factors included lack of established medical dispute-handling mechanisms, problems in legislation, lack of trust and basic health literacy among service users. Situational level risks were contingent on risk factors on the other levels: individual, organisational, and societal.
CONCLUSIONS: Interventions at individual, situational, organisational, and societal levels are needed to systematically address workplace violence against medical staff in China. Specifically, improving health literacy can empower patients, increase trust in medical staff and lead to more positive user experiences. Organizational-level interventions include improving human resource management and service delivery systems, as well as providing training on de-escalation and violence response for medical staff. Addressing risks at the societal level through legislative changes and health reforms is also necessary to ensure medical staff safety and improve medical care in China.

BACKGROUND: Harm from medications is a major patient safety challenge. Most adverse drug events arise when a medication is prescribed or reevaluated. Therefore, interventions in this area may improve patient safety. A medication plan, that is, a plan for continued treatment with medications, may support patient safety. Participation of patients in the design of health care products or services may improve patient safety. Co-design, as in the Double Diamond framework from the Design Council, England, can emphasize patient involvement. As the COVID-19 pandemic brought restrictions to face-to-face co-design approaches, interest in remote approaches increased. However, it is uncertain how best to perform remote co-design. Therefore, we explored a remote approach, which brought together older persons and health care professionals to co-design a medication plan prototype in the electronic health record, aiming to support patient safety.
OBJECTIVE: This study aimed to describe how remote co-design was applied to create a medication plan prototype and to explore participants\' experiences with this approach.
METHODS: Within a case study design, we explored the experiences of a remote co-design initiative with 14 participants in a regional health care system in southern Sweden. Using descriptive statistics, quantitative data from questionnaires and web-based workshop timestamps were analyzed. A thematic analysis of the qualitative data gathered from workshops, interviews, and free-text responses to the survey questions was performed. Qualitative and quantitative data were compared side by side in the discussion.
RESULTS: The analysis of the questionnaires revealed that the participants rated the experiences of the co-design initiative very high. In addition, the balance between how much involved persons expressed their wishes and were listened to was considered very good. Marked timestamps from audio recordings showed that the workshops proceeded according to the plan. The thematic analysis yielded the following main themes: Everyone\'s perspective matters, Learning by sharing, and Mastering a digital space. The themes encompassed what helped to establish a permissive environment that allowed the participants to be involved and share viewpoints. There was a dynamic process of learning and understanding, realizing that despite different backgrounds, there was consensus about the requirements for a medication plan. The remote co-design process seemed appealing, by balancing opportunities and challenges and building an inviting, creative, and tolerant environment.
CONCLUSIONS: Participants experienced that the remote co-design initiative was inclusive of their perspectives and facilitated learning by sharing experiences. The Double Diamond framework was applicable in a digital context and supported the co-design process of the medication plan prototype. Remote co-design is still novel, but with attentiveness to power relations between all involved, this approach may increase opportunities for older persons and health care professionals to collaboratively design products or services that can improve patient safety.

People with early-onset colorectal cancer, under the age of 50, are more likely to experience diagnostic delay and to be diagnosed at later stages of the disease than older people. Advanced stage diagnosis potentially requires invasive therapeutic management at a time of life when these patients are establishing intimate relationships, raising families, building careers and laying foundations for financial stability. Barriers to timely diagnosis at primary care level have been identified but the patient perspective has not been investigated.
Personal accounts of cancer care are increasingly accessed as rich sources of patient experience data. This study uses mixed methods, incorporating quantitative content analysis and qualitative thematic analysis, to investigate patients\' accounts of early-onset colorectal cancer diagnosis published on prominent bowel cancer support websites in the United Kingdom, Australia and New Zealand.
Patients\' perceptions (n = 273) of diagnostic barriers at primary care level were thematically similar across the three countries. Patients perceived that GPs\' low suspicion of cancer due to age under 50 contributed to delays. Patients reported that their GPs seemed unaware of early-onset colorectal cancer and that they were not offered screening for colorectal cancer even when \'red flag\' symptoms were present. Patients described experiences of inadequate information continuity within GP practices and across primary, specialist and tertiary levels of care, which they perceived contributed to diagnostic delay. Patients also reported tensions with GPs over the patient-centredness of care, describing discord related to symptom seriousness and lack of shared decision-making.
Wider dissemination of information about early-onset colorectal cancer at primary care level is imperative given the increasing incidence of the disease, the frequency of diagnostic delay, the rates of late-stage diagnosis and the dissatisfaction with patient experience reported by patients whose diagnosis is delayed. Patient education about diagnostic protocols may help to pre-empt or resolve tensions between GPs\' enactment of value-based care and patients\' concerns about cancer. The challenges of diagnosing early-onset colorectal cancer are significant and will become more pressing for GPs, who will usually be the first point of access to a health system for this growing patient population.

UNASSIGNED: Patients are increasingly reporting about their healthcare experiences online and NHS Trusts are adopting different approaches to responding. However, the sociocultural contexts underpinning these organisational approaches remain unclear. Therefore, we aimed to explore the sociocultural contexts underpinning three organisations who adopted different approaches to responding to online patient feedback.
UNASSIGNED: Recruitment of three NHS Trusts was theoretically guided, and determined based on their different approaches to responding to online patient feedback (a nonresponding organisation, a generic responding organisation and an organisation providing transparent, conversational responses). Ethnographic methods were used during a year of fieldwork involving staff interviews, observations of practice and documentary analysis. Three in-depth case studies are presented.
UNASSIGNED: The first organisation did not respond to or use online patient feedback as staff were busy firefighting volumes of concerns received in other ways. The second organisation adopted a generic responding style due to resource constraints, fears of public engagement and focus on resolving known issues raised via more traditional feedback sources. The final organisation provided transparent, conversational responses to patients online and described a 10-year journey enabling their desired culture to be embedded.
UNASSIGNED: We identified a range of barriers facing organisations who ignore or provide generic responses to patient feedback online. We also demonstrated the sociocultural context in which online interactions between staff and patients can be embraced to inform improvement. However, this represented a slow and difficult organisational journey. Further research is needed to better establish how organisations can recognise and overcome barriers to engaging with online patient feedback, and at pace.

A 35-year old healthy male trauma surgery chief resident, suffered a high-speed motor vehicle collision. The patient sustained the following injuries: a Gustilo-Anderson grade 2 open comminuted intra-articular fracture of the left distal femur (AO 33C3.3), a Hawkins 1A neck fracture of the right talus (AO 81.2A), an undisplaced Lisfranc injury of the right foot comprising avulsion fractures at the base of the 1st, 2nd and 5th metatarsal as well as the cuboid bone suggesting ligament injury and 2nd to 5th carpometacarpal dislocations of the right (non-dominant) hand with comminuted fractures of the capitate, hamate, trapezoid and the base of the fifth metacarpal bone. A staged-treatment approach ensued. An external fixator (ex-fix) was placed over the left knee, followed by definitive fixation of the distal femoral fracture using a Qwix screw, Non-Contact Bridging (NCB) plate and Locking Compression Plate (LCP). An ex-fix was placed over the right wrist, followed by open reduction and k-wire fixation. The talar fracture of the right foot was treated with a single lag screw and the Lisfranc injury was treated non-operatively with four weeks of non-weight bearing cast immobilization. An intensive clinical rehabilitation program was started, including early use of Continuous Passive Motion (CPM), daily non-weightbearing swimming pool exercises, hand, physical and recreational therapy. One year after the injury the patient was rehabilitated and resumed his surgical residency. Two years after the injury, limited flexion and pain in the left leg remains, possibly related to partial union of the femoral fracture. Range of motion (ROM) of the right ankle and wrist remains limited, not causing significant functional impairment. Lessons learned from a patient experience combined with detailed descriptions of injuries, rehabilitation and long term outcomes can be used as a reference for treating patients with comparable injuries.

Multiple Sclerosis (MS) is a complex, lifelong disease. Its effects span across different areas of life and vary strongly. In Switzerland, there is an intense discussion on how to optimize quality of care and patient safety. Patients should be more involved in the management of health care to improve the quality of care from the patient\'s perspective and form a more comprehensive perspective. This multiple-case study explores the question of how persons with MS experience and describe functioning related barriers, facilitating factors, and ethically relevant conflicts. To address this from a comprehensive perspective, the MS core set of the International Classification for Functioning, Disability, and Health (ICF) is used as theoretical framework. To explore barriers, facilitators, and relevant ethical issues, different narrative sources were used for thematic analysis and ICF coding: (a) MS transcripts from DIPEx interviews and (b) an autobiographical book of persons living with MS. Insights that were meaningful for daily practice and education were identified: (a) understanding the importance of environmental circumstances based on narrative sources; (b) understanding the importance of a person\'s individual life situation, and the ability to switch perspectives in the medical field; (c) respect for PwMS\' individuality in health care settings; (d) creating meaningful relationships for disease management and treatment, as well as building trust.

OBJECTIVE: To gain a deeper understanding of online patient feedback moderation through the organisation of Care Opinion in Scotland.
METHODS: An ethnographic study, initially using in-person participant observations, switching to remote methods due to the pandemic. This involved the use of remote observations and interviews. Interviews were carried out with the whole Scottish team (n = 8).
RESULTS: Our results identify three major themes of work found in online patient feedback moderation. The first is process work, where moderators make decisions on how to edit and publish stories. The second is emotional labour from working with healthcare experiences and with NHS staff. The third is the brokering/mediation role of Care Opinion, where they must manage the relationships between authors, subscribing healthcare providers and Scottish Government. Our results also capture that these different themes are not independent and can at times influence the others.
CONCLUSIONS: Our results build on previous literature on Care Opinion and provide novel insights into the emotional and brokering/mediation work they undertake. Care Opinion holds a unique position, where they must balance the interests of the key stakeholders. Care Opinion holds the power to amplify authors\' voices but the power to make changes to services lies with NHS staff and services. Online moderation work is complex, and moderators require support to carry out their work especially given the emotional impact. Further research is planned to understand how patient stories are used by NHS Scotland, and the emotional labour involved with stories, from both the author and NHS staff perspective.