Cause Of Preventable Harm Research Articles

Overtreatment in the United States.

BackgroundOvertreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment.Methods2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment.FindingsThe response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs.ConclusionFrom the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.

Preventing bloodstream infection in IV therapy.

Healthcare-associated infections (HAI) are one cause of preventable harm to patients, and are a clinical, political and economic concern. Vascular access, via a peripheral or central vascular device, is a routine experience for most patients receiving hospital care and is increasingly commonplace in health care at home. Because it is so common, ensuring safe vascular access is an essential focus for all health professionals. All vascular access procedures are invasive, regardless of patient group, therapeutic rationale, the device used, route and site of insertion and particular technique. As such there are inherent risks of patient harm. Many of these risks are well known and include issues such as infiltration, extravasation, phlebitis and pain. Of particular importance is the relationship between intravenous (IV) therapy and infection and how best to prevent HAI, specifically in relation to IV therapy, bloodstream infections, catheter-related bloodstream infections and central-line associated blood stream infections. This article considers the interrelationship between IV therapy bloodstream infections and measures to prevent HAI and summarises key principles in this ongoing endeavour.

Understanding and managing the risk of "head impact" from in-hospital falls: A cross-sectional analysis of data from 166 public hospitals.

Falls are a leading cause of preventable harm in the hospitalized elderly, and head impacts (HIs) can be a precursor to serious injury. The aim of this study was to examine if the risk of fall-related HI can be explained by incident characteristics. All reported falls across public hospital facilities in the state of Queensland, Australia, over a 2-year period were analyzed using univariate and multiple logistic regression. In all, 650 instances of HI were reported across 24 218 falls. Falls due to fainting were associated with elevated HI odds (odds ratio [OR] = 2.00, 95% confidence interval [CI] = 1.30, 3.08). Similarly, falls while walking (OR = 1.48, 95% CI = 1.20, 1.81) and falls during certain time periods, namely, from 11:00 pm to midnight (OR = 1.79, 95% CI = 1.24, 2.59) and between 5:00 am and 6:00 am (OR = 1.50, 95% CI = 1.01, 2.22) were linked to increased HI odds. Falls among males were associated with lowered odds of HI (adjusted odds ratio [AOR] = 0.78, 95% CI = 0.64, 0.74). Results confirm links between characteristics of inpatient falls and the likelihood of HI, and these data can assist risk managers to better target fall prevention strategies. Assisted mobility in high-risk patients and improved environmental lighting are advanced as foci for future research.

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia.

The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety.

Thoracic Epidural Anesthesia and Prophylactic Three Times Daily Unfractionated Heparin Within an Enhanced Recovery After Surgery Pathway for Colorectal Surgery.

Venous thromboembolism (VTE) is a common cause of preventable harm. Perioperative thoracic epidural analgesia (TEA) presents a challenge to optimal VTE prophylaxis. Our primary aim was to characterize missed doses of VTE prophylaxis associated with epidural catheter placement and removal. Our secondary aim was to measure the effect of an enhanced recovery after surgery (ERAS) pathway on the rate of TEA-associated missed VTE prophylaxis. We retrospectively reviewed a prospectively collected database of 1264 colorectal surgery patients at a single academic center. Missed preoperative doses between TEA patients and non-TEA patients were compared. Missed postoperative unfractionated heparin (UFH) doses associated with epidural removal were compared before and after implementation of an ERAS program. Other data collected included demographic data, surgical indication, and thrombohemorrhagic complications. Of the 445 TEA patients, 12.6% missed their preoperative heparin doses compared with 8.4% of patients without epidurals (P = 0.017). Of the TEA patients prescribed 3 times daily UFH, 22.5% missed one or more doses associated with epidural removal. The percent of patients missing at least one dose of UFH on epidural removal dropped from 28.1% before ERAS to 17.9% after the ERAS program (P = 0.023). Seven patients developed VTEs. There were zero epidural hematomas. Thoracic epidural analgesia was associated with a 1.5-fold increased risk of missed dose of preoperative VTE prophylaxis, which was not affected by implementation of an ERAS program. The implementation of an ERAS program reduced missed doses associated with epidural removal. This study highlights the challenge posed by providing VTE prophylaxis in the setting of perioperative neuraxial analgesia.

The Johns Hopkins Venous Thromboembolism Collaborative: Multidisciplinary team approach to achieve perfect prophylaxis.

Venous thromboembolism (VTE) is an important cause of preventable harm in hospitalized patients. The critical steps in delivery of optimal VTE prevention care include (1) assessment of VTE and bleeding risk for each patient, (2) prescription of risk-appropriate VTE prophylaxis, (3) administration of risk-appropriate VTE prophylaxis in a patient-centered manner, and (4) continuously monitoring outcomes to identify new opportunities for learning and performance improvement. To ensure that every hospitalized patient receives VTE prophylaxis consistent with their individual risk level and personal care preferences, we organized a multidisciplinary task force, the Johns Hopkins VTE Collaborative. To achieve the goal of perfect prophylaxis for every patient, we developed evidence-based, specialty-specific computerized clinical decision support VTE prophylaxis order sets that assist providers in ordering risk-appropriate VTE prevention. We developed novel strategies to improve provider VTE prevention ordering practices including face-to-face performance reviews, pay for performance, and provider VTE scorecards. When we discovered that prescription of risk-appropriate VTE prophylaxis does not ensure its administration, our multidisciplinary research team conducted in-depth surveys of patients, nurses, and physicians to design a multidisciplinary patient-centered educational intervention to eliminate missed doses of pharmacologic VTE prophylaxis that has been funded by the Patient Centered Outcomes Research Institute. We expect that the studies currently underway will bring us closer to the goal of perfect VTE prevention care for every patient. Our learning journey to eliminate harm from VTE can be applied to other types of harm. Journal of Hospital Medicine 2016;11:S8-S14. © 2016 Society of Hospital Medicine.

Stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce medication errors, adverse drug events and average length of stay at two paediatric hospitals: a study protocol

IntroductionMedication errors are the most frequent cause of preventable harm in hospitals. Medication management in paediatric patients is particularly complex and consequently potential for harms are greater than in adults....

Predicting risk of adverse drug reactions in older adults.

Adverse drug reactions (ADRs) are common in older adults, with falls, orthostatic hypotension, delirium, renal failure, gastrointestinal and intracranial bleeding being amongst the most common clinical manifestations. ADR risk increases with age-related changes in pharmacokinetics and pharmacodynamics, increasing burden of comorbidity, polypharmacy, inappropriate prescribing and suboptimal monitoring of drugs. ADRs are a preventable cause of harm to patients and an unnecessary waste of healthcare resources. Several ADR risk tools exist but none has sufficient predictive value for clinical practice. Good clinical practice for detecting and predicting ADRs in vulnerable patients includes detailed documentation and regular review of prescribed and over-the-counter medications through standardized medication reconciliation. New medications should be prescribed cautiously with clear therapeutic goals and recognition of the impact a drug can have on multiple organ systems. Prescribers should regularly review medication efficacy and be vigilant for ADRs and their contributory risk factors. Deprescribing should occur at an individual level when drugs are no longer efficacious or beneficial or when safer alternatives exist. Inappropriate prescribing and unnecessary polypharmacy should be minimized. Comprehensive geriatric assessment and the use of explicit prescribing criteria can be useful in this regard.

Effects of implementing educational program about pressure ulcer control on nurses' knowledge and safety of immobilized patients

Background: Pressure ulcers are common problems in healthcare system and produce a significant burden on patients and care providers. Hospital Acquired Pressure Ulcers is a leading cause of preventable harm. It is associated with a significant increase in treatment cost, length of stay, and poor patients’ satisfaction. The aim of this study is to determine the effect of implementing educational program about pressure ulcer control on nurses' knowledge and safety of immobilized patients. Methods: A quasi-experimental design was used to conduct the study on 40 nurses working in the critical care units at Mansoura University Hospital, in addition to 40 patients were randomly assigned from these units previous. A structured questionnaire to collect data related to socio-demographic data for nurses, pressure ulcer nurses' knowledge questionnaires, observational checklist and patient assessment sheet that include Sciodemographic data related to patients, and Braden scale sheet. Results: The present study revealed that: (a) The mean total knowledge scores of nurses were increased immediately after implementation of a program with statistical significant difference compared to pre implementation. (b) The mean total practice scores of nurses were higher immediately after implementing program with a higher statistical significant difference compared to pre implementation. (c) There were a positive correlation between nurses' knowledge and practices with a high statistical significant difference. (d) There were a positive safety immobilized patients as evidence by less incidence of pressure ulcers among study group after received intervention than pre received intervention. Conclusion: This study revealed that nursing staffs’ knowledge and practice about pressure ulcer preventive measures could be improved. Participants in the study reported that they could use the educational program effectively and easily in the prevention of pressure ulcers among their immobilized patients, which decreases the occurrence of pressure ulcers and as well as improved patient outcome. Recommendations: The present study recommended that continues education and in service training program for the nursing staff, which is necessary for the continuously advancing care for patients in this area.

Practices to prevent venous thromboembolism: a brief review

BackgroundVenous thromboembolism (VTE) is a common cause of preventable harm for hospitalised patients. Over the past decade, numerous intervention types have been implemented in attempts to improve the prescription of...

Decreasing Central-Line–Associated Bloodstream Infections in Connecticut Intensive Care Units

Central-line-associated bloodstream infections (CLABSIs) are a significant cause of preventable harm. A collaborative project involving a multifaceted intervention was used in the Michigan Keystone Project and associated with significant reductions in these infections. This intervention included the Comprehensive Unit-based Safety Program, a multifaceted approach to CLABSI prevention, and the monitoring and reporting of infections. The purpose of this study was to determine whether the multifaceted intervention from the Michigan Keystone program could be implemented in Connecticut and to evaluate the impact on CLABSI rates in intensive care units (ICUs). The primary outcome was the NHSN-defined rate of CLABSI. Seventeen ICUs, representing 14 hospitals and 104,695 catheter days were analyzed. The study period included up to four quarters (12 months) of baseline data and seven quarters (21 months) of postintervention data. The overall mean (median) CLABSI rate decreased from 1.8 (1.8) infections per 1,000 catheter days at baseline to 1.1 (0) at seven quarters postimplementation of the intervention. This study demonstrated that the multifaceted intervention used in the Keystone program could be successfully implemented in another state and was associated with a reduction in CLABSI rates in Connecticut. Moreover, even though the statewide baseline CLABSI rate in Connecticut was low, rates were reduced even further and well below national benchmarks.

Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial

Catheter-associated urinary tract infection (CAUTI) is a major preventable cause of harm for patients in hospital. We aimed to establish whether short-term routine use of antimicrobial catheters reduced risk of CAUTI compared with standard polytetrafluoroethylene (PTFE) catheterisation. In our parallel, three group, multicentre, randomised controlled superiority trial, we enrolled adults (aged ≥16 years) requiring short-term (≤14 days) catheterisation at 24 hospitals in the UK. Participants were randomly allocated 1:1:1 with a remote computer allocation to receive a silver alloy-coated catheter, a nitrofural-impregnated catheter, or a PTFE-coated catheter (control group). Patients undergoing unplanned catheterisation were also included and consent for participation was obtained retrospectively. Participants and trial staff were unmasked to treatment assignment. Data were collected by trial staff and by patient-reported questionnaires for 6 weeks after randomisation. The primary outcome was incidence of symptomatic urinary tract infection for which an antibiotic was prescribed by 6 weeks. We postulated that a 3·3% absolute reduction in CAUTI would represent sufficient benefit to recommend routine use of antimicrobial catheters. This study is registered, number ISRCTN75198618. 708 (10%) of 7102 randomly allocated participants were not catheterised, did not confirm consent, or withdrew, and were not included in the primary analyses. Compared with 271 (12·6%) of 2144 participants in the control group, 263 (12·5%) of 2097 participants allocated a silver alloy catheter had the primary outcome (difference -0·1% [95% CI -2·4 to 2·2]), as did 228 (10·6%) of 2153 participants allocated a nitrofural catheter (-2·1% [-4·2 to 0·1]). Rates of catheter-related discomfort were higher in the nitrofural group than they were in the other groups. Silver alloy-coated catheters were not effective for reduction of incidence of symptomatic CAUTI. The reduction we noted in CAUTI associated with nitrofural-impregnated catheters was less than that regarded as clinically important. Routine use of antimicrobial-impregnated catheters is not supported by this trial. UK National Institute for Health Research Health Technology Assessment Programme.

Types of urethral catheter for reducing symptomatic urinary tract infections in hospitalised adults requiring short-term catheterisation: multicentre randomised controlled trial and economic evaluation of antimicrobial- and antiseptic-impregnated urethral catheters (the CATHETER trial)

Catheter-associated urinary tract infection (CAUTI) is a major preventable cause of harm for patients in hospital and incurs significant costs for health-care providers such as the UK NHS. Many preventative strategies and measures have been introduced to minimise CAUTI risk, including the use of antimicrobial catheters. However, there is considerable uncertainty regarding their usefulness in terms of reducing symptomatic CAUTI, and whether or not they are cost-effective.Do antimicrobial catheters reduce the rate of symptomatic urinary tract infection (UTI) during short-term hospital use and is their use cost-effective for the UK NHS?A pragmatic multicentre UK randomised controlled trial comparing three catheters as they would be used in the UK NHS: antimicrobial-impregnated (nitrofurazone) and antiseptic-coated (silver alloy) catheters with the standard polytetrafluoroethylene (PTFE)-coated catheters. Economic evaluation used a decision model populated with data from the trial. Sensitivity analysis was used to explore uncertainty.Relevant clinical departments in 24 NHS hospitals throughout the UK.Adults requiring temporary urethral catheterisation for a period of between 1 and 14 days as part of their care, predominantly as a result of elective surgery.Eligible participants were randomised 1 : 1 : 1 to one of three types of urethral catheter in order to make the following pragmatic comparisons: nitrofurazone-impregnated silicone catheter compared with standard PTFE-coated latex catheter; and silver alloy-coated hydrogel latex catheter compared with standard PTFE-coated latex catheter.The primary outcome for clinical effectiveness was the incidence of UTI at any time up to 6 weeks post randomisation. This was defined as any symptom reported during catheterisation, up to 3 days or 1 or 2 weeks post catheter removal or 6 weeks post randomisation combined with a prescription of antibiotics, at any of these times, for presumed symptomatic UTI. The primary economic outcome was incremental cost per quality-adjusted life-year (QALY). Health-care costs were estimated from NHS sources with QALYs calculated from participant completion of the European Quality of Life-5 Dimensions (EQ-5D).Outcome analyses encompassed 6394 (90%) of 7102 participants randomised. The rate of symptomatic UTI within 6 weeks of randomisation was 10.6% in the nitrofurazone group (n = 2153; -2.1% absolute risk difference), 12.5% in the silver alloy group (n = 2097; -0.1% absolute risk difference) and 12.6% in the PTFE group (n = 2144). The effect size {odds ratio (OR) [97.5% confidence interval (CI)]} was 0.82 (97.5% CI 0.66 to 1.01) for nitrofurazone (p = 0.037) and 0.99 (97.5% CI 0.81 to 1.22) for silver alloy (p = 0.92) catheters. The nitrofurazone catheters were more likely to cause discomfort during use and on removal. The primary economic analysis suggested that nitrofurazone-impregnated catheters would be, on average, the least costly (> £7 less than PTFE) and most effective option at current NHS prices. There was a 73% chance that nitrofurazone would be cost saving and an 84% chance that the incremental cost per QALY would be < £30,000. At the trial price (£6.46), silver alloy catheters were very unlikely to be cost-effective. These results were unchanged in sensitivity analyses, although when the length of stay cost was excluded the incremental cost per QALY for nitrofurazone against PTFE was £28,602.The trial estimate of clinical effectiveness for nitrofurazone-impregnated catheters was less than the pre-specified minimum absolute risk difference that we considered important (-3.3%), and the surrounding CI included zero, indicating that any reduction in catheter-associated UTI was uncertain. Economic analysis, although associated with uncertainty, suggested that nitrofurazone-impregnated catheters may be cost-effective for the NHS. The trial ruled out the possibility that silver alloy-coated catheters might reach the pre-set degree of clinical effectiveness and that their use was unlikely to be cost-effective. These findings should be considered by patients, clinicians and health-care policy-makers to determine whether or not a change in practice is worthwhile. Future research should be aimed at determining the minimum clinically important difference in terms of CAUTI prevention in comparative trials, and to identify reliable methods which can detect the impact of the intervention on quality of life and other drivers of cost, when the intervention is a subsidiary part of overall treatment plans.

Diagnostic Test Studies in Nephrology: Quantity, Quality, and Scope

Diagnostic errors represent an important cause of preventable harm in health care that may be reduced through evidence-based choice, use, and interpretation of diagnostic tests. We hypothesized that diagnostic errors are reduced through evidence-based choice, use, and interpretation of diagnostic tests. Retrospective cohort study. Diagnostic test studies. Publications from 1966-2008 retrieved from MEDLINE. The Quality of Diagnostic Accuracy Studies (QUADAS) tool. Number and coverage of diagnostic studies in nephrology and methodological quality of the test accuracy subset. Fewer diagnostic studies were published in nephrology than other areas of internal medicine, although the proportion of total citations that were diagnostic studies (4.9% ± 2.8% [SD]) was not statistically different from other specialties (P = 0.2). Within nephrology, some topic areas (eg, urinary tract infections) were over-represented, whereas others (eg, acute kidney injury) had relatively few diagnostic studies (range, 2.7%-12.5%). Examining the randomly selected subset of studies that were diagnostic test accuracy studies (120) showed variable quality. Ninety-seven percent (116 of 120) of studies adequately described index test procedure, but only 27% (32 of 120) adequately blinded investigators to results of index tests, and 36% (43 of 120), to results of reference tests. The quality of nephrology diagnostic test accuracy studies has not improved substantially during the past 30 years. Comparing nephrology with other specialties, some potential inequalities of scale could not be addressed, which may influence research output results across specialties. Diagnostic research in nephrology is published less frequently than most other medical specialties. The quality of diagnostic test accuracy studies that are published is variable and leaves room for improvement.

Surveillance Bias in Outcomes Reporting

THE PREVALENCE AND EXTENT OF PUBLIC REPORTING of adverse medical outcomes are increasing. Many private, public, and government Web sites rank hospitals and report scores on selected quality measures. Health care consumers, including referring physicians, individual patients, and insurers, can use these data to inform decision making by selecting hospitals with better outcomes. However, the science of outcome reporting is young and lags behind the desires of the public in this information age. Reporting quality measures may have benefits but also may pose risks from unintended consequences. When validating outcome measures, the main focus has been strict definitions for numerators to clearly identify cases and for denominators to identify patients at risk. Standardized surveillance for events within the population of those at risk has received little attention, and as a result, surveillance bias is likely an important source of error in currently reported outcome measures. Surveillance bias, a nonrandom type of information bias, refers to the idea that “the more you look, the more you find.” It occurs when some patients are followed up more closely or have more diagnostic tests performed than others, often leading to an outcome diagnosed more frequently in the more closely monitored group. In an article on biases inherent to clinical research, Sackett used the phrase “unmasking (detection signal) bias” to explain how “an innocent exposure may become suspect if, rather than causing a disease, it causes a sign or symptom which precipitates a search for the disease.” As a result, differences in outcomes may be related to surveillance bias rather than differences in quality. If ignored, flawed causal inferences could be suggested from differential rates identified between groups. Surveillance bias is a well-known concept in epidemiology yet is seldom considered in published clinical studies. For example, deep vein thrombosis (DVT) is a significant cause of preventable harm and a commonly monitored quality-of-care measure. DVT is a common, lifethreatening complication among patients who have sustained trauma. Because injured patients are at increased risk for DVT, some clinicians use duplex ultrasound to screen highrisk asymptomatic trauma patients for DVT. Other clinicians argue this approach is neither clinically necessary nor cost-effective and therefore do not routinely screen for DVT in trauma patients. This clinical uncertainly leads to variability in the use of screening duplex ultrasound, creating variability in rates of DVT identified and reported—a typical example of surveillance bias. Evidence for surveillance bias in DVT reporting after trauma is well documented. For instance, after implementation of a DVT screening guideline at one trauma center, duplex ultrasound rates increased 4-fold and DVT rates increased 10-fold. Within the National Trauma Data Bank, DVT rates were 7-fold higher at hospitals in the highest quartile of use of vascular ultrasound, and patients treated at hospitals that performed more duplex ultrasounds were twice as likely to have DVT reported, even controlling for other patient risk factors. Surveillance bias also is an important factor in other highprofile publicly reported outcome measures. For example, rates of central line–associated bloodstream infections (BSIs) increased 3-fold with the use of computer automated surveillance, suggesting that “surveillance practice may complicate interinstitutional comparisons of publicly reported central line–associated BSI rates.” The hazard of error caused by surveillance bias will likely increase with increasing use of penalties and rewards for performance on quality measures. Surveillance bias also has the potential to pose significant harms. For instance, patients may be harmed because clinicians will not know if quality of care is improving, and incentives to improve outcomes may encourage clinicians to avoid appropriate diagnostic testing to minimize reported complications. Because performance measures do not specify surveillance, outcomes that are not sought ordinarily will not be detected. This potential for unintended consequences was summarized in a comment by Alam and Velmahos as: “No screening, no DVT, no punishment.” Thus,

See-saw nystagmus.

<h3>Abstract</h3> Clinical handover has been identified as a "major preventable cause of harm" by the Royal College of Physicians (RCP). Whilst working at a London teaching hospital from August 2013, we noted substandard weekend handover of medical patients. The existing pro forma was filled incompletely by day doctors so it was difficult for weekend colleagues to identify unwell patients, with inherent safety implications. Furthermore, on-call medical staff noted that poor accessibility of vital information in patients9 files was affecting acute clinical management. We audited the pro formas over a six week period (n=83) and the Friday ward round (WR) entries for medical inpatients over two weekends (n=84) against the RCP9s handover guidance. The results showed poor documentation of several important details on the pro formas, for example, ceiling of care (4%) and past medical history (PMH) (23%). Problem lists were specified on 62% of the WR entries. We designed new handover pro formas and 9Friday WR sheets9 to provide prompts for this information and used Medical Meetings and emails to explain the project9s aims. Re-audit demonstrated significant improvement in all parameters; for instance, PMH increased to 52% on the pro formas. Only 10% of Friday WR entries used our sheet. However, when used, outcomes were much better, for example, problem list documentation increased to 100%. In conclusion, our interventions improved the provision of crucial information needed to prioritise and manage patients over the weekend. Future work should further highlight the importance of safe handover to all doctors to induce a shift in culture and optimise patient care.