Safety Incidents Research Articles

Regulatory decentralization and food safety: evidence from China

AbstractIt is not clear, a priori, whether a centralized or decentralized institutional arrangement is better at providing public goods. This study investigates how decentralization of regulatory authority affects public good provision, focusing on food safety. Using a natural experiment that transfers food safety regulatory authority over the food processing and manufacturing sector from provincial to city‐level governments, we find a 51% decrease in the average number of food safety incidents within cities that experienced the decentralization reform. Decentralization reduces food safety incidents by rectifying information asymmetry in food safety regulations and by increasing local food safety laws and regulations. Additional analyses show that decentralization primarily improves the food safety of larger and more experienced firms, and it has not harmed the total revenue of large‐scale food processing and manufacturing firms. Our study demonstrates the importance of information available to regulatory authorities in food safety regulation and highlights the role of local information in the decentralized provision of public goods.

Effects of pregabalin combined with tramadol/paracetamol on acute pain in patients with CT-guided puncture localization of pulmonary nodules

ObjectiveTo investigate the effects of pregabalin combined with tramadol/paracetamol on acute pain in patients with CT-guided puncture localization of pulmonary nodules. Materials and MethodsIn this randomized, placebo-controlled and single-center study, 120 patients were allocated randomly to four groups: the control group (Group P), the pregabalin-placebo group (Group BP), the tramadol/paracetamol-placebo group (Group AP), and the pregabalin-tramadol/paracetamol group (Group AB). The primary outcome was the NRS (Numerical Rating Scale) score. Other outcomes included systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), pulse oxygen saturation (SpO2), the incidence of moderate to severe pain, the analgesia recovery ratio, the incidence of adverse drug reactions and patients’ satisfaction. ResultsNo significant interaction was detected between the interventions (P = 0.752). The NRS score of the Taking pregabalin group and the Taking tramadol/paracetamol group were significantly lower than those of the Not-taking pregabalin group and the Not-taking tramadol/paracetamol group respectively (P < 0.05). There was significant difference in the NRS scores among the four groups (P < 0.001). The NRS score of Group AB was significantly lower than that of Group P (P < 0.001), Group BP (P < 0.001) and Group AP (P = 0.001). At the same time, the NRS scores of Group BP (P < 0.001) and Group AP (P < 0.001) were significantly lower than those of Group P, but there was no significant difference between Group BP and Group AP (P = 1.000). The SBP, DBP, HR, the incidence of moderate to severe pain and the analgesia recovery ratio of Group AB were significantly lower than those of Group P (P < 0.05), while the SpO2 and the number of people who were very satisfied were significantly higher than those of Group P (P < 0.05). There was no significant difference in the incidence of adverse drug reactions among the four groups (P = 0.272). ConclusionsThe combination or single use of pregabalin and tramadol/paracetamol can effectively relieve the acute pain after localization. Pregabalin combined with tramadol/paracetamol has the best analgesic effect and significantly reduces the hemodynamic fluctuations, with high safety and low incidence of adverse drug reactions, which has a certain clinical popularization and application value.

A multifaceted risk management program to improve the reporting rate of patient safety incidents in primary care: a cluster-randomised controlled trial

BackgroundWhile patient safety incident reporting is of key importance for patient safety in primary care, the reporting rate by healthcare professionals remains low. This study aimed to assess the effectiveness of a risk management program in increasing the reporting rate within multiprofessional primary care facilities.MethodsA nation-wide cluster-randomised controlled trial was performed in France, with each cluster defined as a primary care facility. The intervention included professional e-learning training, identification of a risk management advisor, and multidisciplinary meetings to address incident analysis. In the first observational period, a patient safety incident reporting system for professionals was implemented in all facilities. Then, facilities were randomised, and the program was implemented. Incidents were reported over the 15-month study period. Quasi-Poisson models were used to compare reporting rates.ResultsThirty-five facilities (intervention, n = 17; control, n = 18) were included, with 169 and 232 healthcare professionals, respectively, involved. Overall, 7 out of 17 facilities carried out the entire program (41.2%), while 6 did not hold meetings (35.3%); 48.5% of professionals logged on to the e-learning website. The relative rate of incidents reported was 2.7 (95% CI = [0.84–11.0]; p = 0.12). However, a statistically significant decrease in the incident rate between the pre-intervention and post-intervention periods was observed for the control arm (HR = 0.2; 95% CI = [0.05–0.54]; p = 0.02), but not for the intervention arm (HR = 0.54; 95% CI = [0.2–1.54]; p = 0.23).ConclusionThis program didn’t lead to a significant improvement in the patient safety incident reporting rate by professionals but seemed to sustain reporting over time. Considering that the program was fully implemented in only 41% of facilities, this highlights the difficulty of implementing such multidisciplinary programs in primary care despite its adaptation to the setting. A better understanding of how risk management is currently organized in these multiprofessional facilities is of key importance to improve patient safety in primary care.Trial registrationsThe study has been registered at clinicaltrials.gov (NCT02403388) on 30 March 2015.

Review of Integrated Management Systems to Re-Engineer Existing Nonconformances Troubleshooting System

Total quality management (TQM) is a strategic philosophy that has adopted kaizen activities which drives the business to carry out activities effectively to yield the best desired output, hence, a profitable organization. The kaizen philosophy acts as a catalyst in productivity rate and integrated management systems (IMS) which results in drastic improvements. When the nonconformity arises within the process, the accuracy of the problem solving determines quality of preventive action, therefore the preventive action should be accompanied by the opportunity of improvement from the raised nonconformance. This research seeks to add more knowledge and upgrade technology of problem-solving models relating to the integrated management systems by examining various troubleshooting models for problem solving and preventive action related to quality nonconformances, safety incidents and engineering breakdowns. Hence, the aim of this research is for troubleshooting model technique enhancement for issues related to process engineering, quality management systems and occupational health and safety by creating a model which analyses kaizen projects from the corrective and preventive action analysis of nonconformances. The proposed troubleshooting model was developed using lean techniques and risk rating tools; it was then applied to the case study company for simulation and the outcomes resulted in the closure of nonconformances and continual improvement of future projects. The proposed model is more advantageous to the manufacturing industries seeking to improve their Corrective Action and Preventive Action (CAPA) systems.

Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study

IntroductionAt least 10% of hospital admissions in high-income countries, including Australia, are associated with patient safety incidents, which contribute to patient harm (‘adverse events’). When a patient is seriously harmed,...

Application of the System‐Theoretic Process Analysis (STPA) technique to enabling systems in the rail industry

AbstractInvestigations into several recent railway safety incidents have concluded that failures of enabling systems contributed significantly to the root cause of those incidents, suggesting a tendency towards poor management of safety risk associated with subsystems outside the immediate System of Interest (SoI) boundary. This paper examines whether better application of systems thinking to the analysis of hazards, through use of the System‐Theoretic Process Analysis (STPA) technique, could have enabled safety risk to be better identified and managed in the circumstances surrounding a serious derailment that occurred in Victoria, Australia in February 2020.

Evaluation of the Ghanaian Healthcare Environment and Patient Safety context using the SEIPS model of Work System

Objective: This paper aimed to evaluate hazards contributing to patient safety incidents within Ghana’s healthcare system using a human factors engineering model to trace risks across interacting domains. Methods: The Systems Engineering Initiative for Patient Safety (SEIPS) model framed analysis of challenges within the dimensions of healthcare Personnel, Tasks, Tools/Technology, Environment, Organization and Processes. Over 25 studies provided multi-dimensional empirical evidence, with insights synthesized across domains to depict risk pathways enabling patient harm events. Conclusions: The analysis reveals a severely overburdened and constrained healthcare ecosystem unable to reliably deliver safe care processes – with risks stemming from financing limitations, infrastructure deficits, equipment failures, health worker shortages and skills gaps, supply variability, leadership prioritization, and information systems. Solutions require coordinated commitment across these interdependent aspects. Recommendations: Six priority actions are proposed spanning governance, culture, staffing, health IT, quality programs and financing – grounded in concrete evidence-based initiatives but connected through systems thinking. Significance: This systems analysis substantially advances understanding of patient safety threats in Ghana to motivate action. The model approach further demonstrates application of human factors engineering methods to diagnose healthcare quality challenges in limited-resource settings.

Analisis Pengetahuan dan Kepatuhan Perawat dalam Penerapan Pencegahan Resiko Pasien Jatuh di Ruang Rawat Inap Rumah Sakit PKU Muhammadiyah Kartasura

Patient safety includes safe care, risk assessment, risk management, and incident reporting. The most frequent patient safety incidents are falls, which rank second after medication errors. Objective: To analyze the knowledge and compliance of nurses in implementing prevention for patients at risk of falls in the inpatient room at PKU Muhammadiyah Kartasura Hospital. Method: This research uses mixed methods, which combines collection, analysis and mixing of quantitative and qualitative data in one study. The research population was 20 nurses at the PKU Muhammadiyah Kartasura Hospital Inpatient Installation in 2024. Results: Respondents aged 26-35 years (45%), female (85%), last education was D-III Nursing (80%), and length of service 1-5 years (40%). Most respondents had a high level of knowledge (70%), and high compliance (80%). Nurses with poor knowledge who did not comply were 66.7%, while all nurses with good knowledge complied 100%. Chi-square analysis was 0.003, showing that compliance was influenced by level of knowledge, length of work, age, and self-awareness. Conclusion: A nurse's compliance cannot be separated from the nurse's level of knowledge in implementing risk prevention for patient falls. Apart from the level of knowledge, length of work and a person's age also greatly influence the implementation of risk prevention for patient falls, a person's lack of self-awareness can also influence a person's compliance to progress and be successful.

Lithium battery state of health estimation using real-world vehicle data and an interpretable hybrid framework

Accurate point estimation and uncertainty estimation of the state of health (SOH) of battery systems are crucial for alleviating user range anxiety and preventing battery safety incidents. On top of approximately 28 million real-world electric vehicle operation data samples, this paper embeds the categorical boosting algorithm as the base learner of the natural gradient boosting, proposing a novel interpretable N-CatBoost hybrid framework to achieve precise point estimation and uncertainty estimation of the battery SOH. Deep charging segments are selected to calculate the initial capacity, and the nonlinear decay trend of the capacity is derived through the Savitzky-Golay filter. Based on the influencing factors of capacity degradation, health features characterizing battery aging are extracted from electric vehicle data as model inputs. The model's hyperparameters are optimized using the particle swarm optimization algorithm, and it is compared with seven other popular machine learning algorithms. The results indicate that the proposed N-CatBoost model achieves the highest estimation accuracy, with mean absolute percentage error and root mean square error of 0.817 % and 1.156 Ah, respectively. In addition, the Shapley additive explanation method is utilized to make the model interpretable, providing full transparency of all predicted values. More importantly, the developed N-CatBoost model can achieve uncertainty estimation of its predictions, with 100 % of the actual capacity values successfully falling within the model's 99 % prediction interval. Therefore, the proposed N-CatBoost model is a reliable and effective method with great potential for deployment on the cloud side for the SOH estimation of batteries in large-scale vehicles.

Duty of candour and clinically significant accidental or unintended exposures: revisiting the definition of moderate harm for patient safety incidents involving ionizing radiation.

To explore a quantitative interpretation of the term 'moderate harm' as applied to the triggering of the duty of candour associated with clinically significant accidental and unintended exposures to ionizing radiation. Current definitions of 'moderate harm' were matched to the lay descriptions of disease and injury states used in the calculation of detriment as disability-adjusted life years (DALY) by the World Health Organization, to obtain a value of detriment associated with 'moderate harm'. Published conversion factors between effective dose and DALY were used to calculate the effective dose associated with the same detriment. The DALY loss associated with a moderate harm incident is estimated as 0.0216 years. This corresponds to the detriment resulting from exposure to ionizing radiation of 21 mSv. An effective dose of 21 mSv relates to a probability of induced cancer of 0.0012. The results obtained closely match existing guidance although the method used is completely different. It is concluded that there is no evidence to change the existing guidance on the triggering of DoC in radiation incidents. An alternative approach to linking 'moderate harm' and radiation detriment has reinforced existing guidance.

Learning from patient safety incidents: The Green Cross method.

Hospitals can improve how they learn from patient safety incidents. The Green Cross method, a proactive reporting and learning method, is one strategy to meet this challenge. In it, nurses play a key role. However, describing its impact on learning from the users' perspective is important. This study aimed to describe nurses' experiences of learning from patient safety incidents before and 3 months after implementing the Green Cross method in a postanaesthesia care unit. A qualitative study with an inductive descriptive design with focus group interviews was conducted before and 3 months after implementing the Green Cross method to assess its impact. The data were analysed using qualitative content analysis. The study was conducted in a postanaesthesia care unit in a Norwegian hospital trust. Before implementing the Green Cross method, participants indicated limited openness and learning, including the subcategories 'Lack of openness hampers learning', 'Adverse events were taken seriously' and 'Insufficient visible improvements'. After implementing the Green Cross method, participants indicated the emergence of a learning environment, including the subcategories 'Transparency increases learning', 'Increased patient safety awareness' and 'Committed to quality improvements'. Implementing the Green Cross method in a postanaesthesia care unit positively impacted openness and nurses' patient safety awareness, which is crucial for learning and improving quality. The Green Cross method could be useful for organizational learning and facilitating learning from patient safety incidents through transparency, discussion and involvement of nursing staff.

FACTORS RELATED TO THE QUALITY OF HANDOVER OF SITUATION, BACKGROUND, ASSESSMENT, RECOMMENDATION (SBAR) METHODS ON INTERNAL PATIENT TRANSFER

Communication errors are one of the causes of patient safety incidents. Handover of internal patient transfers using the SBAR methodis a form of communication whose implementation has not been carried out optimally. Purpose: To determine the factors associatedwith the quality of the SBAR handover method in internal patient transfers. Research method: Type of correlational quantitativeresearch. Cross-sectional research design. The population consisted of 94 nurses who carried out internal patient transfers. Thesample consisted of 76 nurses who transferred level 0 patients. The sampling technique uses purposive sampling. Measuring toolsuse questionnaires and observation sheets. Statistical tests use the Chi-Square test. Results: Nurse attitude (P-value = 0.000) andOdds Ratio 8.543, receive motivation (P-value = 0.003) and Odds Ratio 5.315, Head of Space leadership (P-value = 0.001) and OddsRatio 6.367, and head of room supervision (P-value = 0.002) and Odds Ratio 5.769. has a P-value of &lt;0.005, using Chi-Square Testanalysis and Logistic Regression to see the most influential variable, nurse attitude. Conclusion: The attitude sub-variable is the mostinfluential on the quality of SBAR method handover in internal patient transfer. Suggestion: Hospitals must conduct periodic andcontinuous evaluations of handover activities. The nurse's attitude that needs to be improved is the understanding of the sta ges andadjustment of the appropriate internal transfer time of the patient.

Research on the detection algorithm of electric workers in the limited spaces of hydroelectric power station

Safety incidents in limited spaces during power production frequently occur, often leading to disrupted schedules and, in severe cases, substantial economic losses. Traditional detection methods for electric workers in the limited spaces of hydroelectric power stations suffer from limitations such as insufficient feature expression capability and low accuracy. To address these issues, this paper proposes a novel detection method based on an improved You Only Live Once (YOLO) model combined with person re-identification. Firstly, the YOLO model is optimized by enhancing the Backbone network, Neck network, and Head network, and by incorporating a screening and matching algorithm based on anchor-free boxes. Subsequently, by integrating person re-identification, an improved YOLO model fused with the C-JDE model (FD-YOLO) is proposed to enhance the detection accuracy of electric workers in the limited space. Experimental results show that the average accuracy indicators, AP50 and AP50:95, of the proposed model have both increased by more than 12 percentage points compared to the traditional YOLO model, which demonstrates that the improved FD-YOLO model significantly enhances the detection accuracy of electric workers in the limited spaces of hydroelectric power stations. The research outcomes provide valuable technical support for the intelligent management of power stations.

The second victim phenomenon: A qualitative study among bachelor’s degree nursing students within the clinical learning environment

AimThis study explores and describes the second victim phenomenon in nursing students in association with the characteristics of the clinical learning environment and the clinical supervision process. DesignQualitative design using conventional content analysis and summative content analysis approaches. MethodsFrom September 2022 to July 2023, in-depth semi-structured individual interviews were conducted with a purposive sample of 10 undergraduate nursing students. ResultsSix main themes were developed: ‘defining the physical and psychological responses after the most significant patient safety incident’, ‘analyzing the characteristics of patient safety incidents’, ‘creating a safe learning environment to provide the best care for patients’, ‘developing mentorship capabilities and qualities for an ideal follow up of students as a second victim’, ‘providing resources and integrating support structures to second victim nursing students during their clinical learning’, and ‘considering the cooperation and coordination between the health institution and the higher education institutions.’ ConclusionNursing students become second victims during their clinical placement. The clinical learning environment and mentoring characteristics influence the second victim experience.

Accuracy assessment of patient safety incident (PSI) codes and present-on-admission (POA) indicators: a cross-sectional analysis using the Patient Safety Incidents Inquiry (PSII) in Korea

BackgroundAmong the various methods used, administrative data collected for claims and billing purposes, such as diagnosis codes and present-on-admission (POA) indicators, can easily be employed to assess patient safety status. However, it is crucial that administrative data be accurate to generate valid estimates of adverse event (AE) occurrence. Thus, we aimed to evaluate the accuracy of diagnosis codes and POA indicators in patients with confirmed AEs in the hospital admission setting.MethodsWe analysed the diagnosis codes of 1,032 confirmed AE cases and 6,754 non-AE cases from the 2019 Patient Safety Incidents Inquiry, which was designed as a cross-sectional study, to determine their alignment with the Korean Patient Safety Incidents (PSIs) Code Classification System. The unit of analysis was the individual case rather than the patient, because two or more AEs may occur in one patient. We examined whether the primary and secondary diagnostic codes had PSIs codes matching the AE type and checked each PSI code for whether the POA indicator had an ‘N’ tag. We reviewed the presence of PSI codes in patients without identified AEs and calculated the correlation between the AE incidence rate and PSI code and POA indicator accuracy across 15 hospitals.ResultsNinety (8.7%) of the AE cases had PSI codes with an ‘N’ tag on the POA indicator compared to 294 (4.4%) of the non-AE cases. Infection- (20.4%) and surgery/procedure-related AEs (13.6%) had relatively higher instances of correctly tagged PSI codes. We did not identify any PSI codes for diagnosis-related incidents. While we noted significant differences in AE incidence rates, PSI code accuracy, and POA indicator accuracy among the hospitals, the correlations between these variables were not statistically significant.ConclusionCurrently, PSI codes and POA indicators in South Korea appear to have low validity. To use administrative data in medical quality improvement activities such as monitoring patient safety levels, improving the accuracy of administrative data should be a priority. Possible strategies include targeted education on PSI codes and POA indicators and introduction of new evaluation indicators regarding the accuracy of administrative data.

Early-warning of unsafe hoisting operations: An integration of digital twin and knowledge graph

Unsafe hoisting operations have been consistently associated with numerous safety incidents involving tower cranes. Currently, the predominant measures to mitigate these operations center around comprehensive training and education, emphasizing standardized protocols prior to hoisting activities. Despite concerted efforts in this direction, a conspicuous research gap persists in early-warning mechanisms during the construction phase. This paper aims to address this gap by proposing an innovative early-warning methodology, inspired by the principles of digital twin and knowledge graph. We firstly introduce a digital twin framework designed to mirror the real-time operational status of the tower crane. This framework enables the immediate detection of deviations or infractions as they occur. Subsequently, we develop a knowledge graph capable of promptly identifying unsafe hoisting operations by leveraging real-time data obtained from the digital twin. To validate the efficacy of our proposed methodology, we construct a scaled-down replica of a tower crane and establish a tailored digital twin system. The findings of a series of experimental trials prominently underscore the system's capability to generate timely alerts in response to unsafe hoisting operations while maintaining an impressively low rate of false alarms.

Systematic review of types of safety incidents and the processes and systems used for safety incident reporting in care homes.

To identify the safety incident reporting systems and processes used within care homes to capture staff reports of safety incidents, and the types and characteristics of safety incidents captured by safety incident reporting systems. Systematic review following PRISMA reporting guidelines. Databases were searched January 2023 for studies published after year 2000, written in English, focus on care homes and incident reporting systems. Data were extracted using a bespoke data extraction tool, and quality was assessed. Data were analysed descriptively and using narrative synthesis, with types and characteristics of incidents analysed using the International Classification for Patient Safety. Databases were CINAHL, MEDLINE, PsycINFO, EMBASE, HMIC, ASSISA, Nursing and Allied Health Database, MedNar and OpenGrey. We identified 8150 papers with 106 studies eligible for inclusion, all conducted in high-income countries. Numerous incident reporting processes and systems were identified. Using modalities, typical incident reporting systems captured all types of incidents via electronic computerized reporting, with reports made by nursing staff and captured information about patient demographics, the incident and post-incident actions, whilst some reporting systems included medication- and falls-specific information. Reports were most often used to summarize data and identify trends. Incidents categories most often were patient behaviour, clinical process/procedure, documentation, medication/intravenous fluids and falls. Various contributing and mitigating factors and actions to reduce risk were identified. The most reported action to reduce risk was to improve safety culture. Individual outcomes were often reported, but social/economic impact of incidents and organizational outcomes were rarely reported. This review has demonstrated a complex picture of incident reporting in care homes with evidence limited to high-income countries, highlighting a significant knowledge gap. The findings emphasize the central role of nursing staff in reporting safety incidents and the lack of standardized reporting systems and processes. The findings from this study can inform the development or adaptation of safety incident reporting systems in care home settings, which is of relevance for nurses, care home managers, commissioners and regulators. This can help to improve patient care by identifying common safety issues across various types of care home and inform learning responses, which require further research. This study addresses a gap in the literature on the systems and processes used to report safety incidents in care homes across many countries, and provides a comprehensive overview of safety issues identified via incident reporting. PRISMA. A member of the research team is a patient and public representative, involved from study conception.

Enhancing nutritional formula expiry monitoring: A quality improvement project in a tertiary-level hospital in Riyadh, Saudi Arabia.

Nutrition is a vital part of any treatment plan. This may include providing nutritional formulas during hospitalization and afterward. However, reported incidents showed that we had issues with nutritional formula expiry monitoring at our hospital with low compliance to Joint Commission International Standards (MMU.3.1): "There is a process for storage of medications and nutritional products that require special consideration." Therefore, a "Nutritional Formula Expiry Monitoring" project was created to decrease hospital safety incidents related to expired nutritional formulas from an average of 28 in 2015 to zero by 2018. A quality improvement model was developed to map the existing formula processes. Several proposed ideas were tested including performing a hospital-wide audit to examine possible risks and practices, developing a hospital policy, flow charts, forms, and audit tools, and providing educational presentations. A total of 40 units in the hospital were included in the implementation. After implementing all the change ideas, the system for monitoring the expiry of the nutritional formula was standardized, and the number of reported incidents related to the nutritional formula decreased from 28 in the third quarter of 2015 to one in the first quarter of 2018. This project provided step-by-step instructions for improving storing, delivering, and monitoring of nutritional formula. Consequently, the incidences of expired formula and cost wasting were successfully decreased, which increased safe administration and prevented patients from receiving expired nutritional formula. This project can be implemented in various healthcare settings.

Patient safety in orthodontic care: a scoping literature review with proposal for terminology and future research agenda

BackgroundKnowledge about patient safety in orthodontics is scarce. Lack of standardisation and a common terminology hinders research and limits our understanding of the discipline. This study aims to 1) summarise current knowledge about patient safety incidents (PSI) in orthodontic care by conducting a systematic literature search, 2) propose a new standardisation of PSI terminology and 3) propose a future research agenda on patient safety in the field of orthodontics.MethodsA systematic literature search was performed in the main online sources of PubMed, Web of Science, Scopus and OpenGrey from their inception to 1 July 2023. Inclusion criteria were based on the World Health Organization´s (WHO) research cycle on patient safety. Studies providing information about the cycle’s steps related to orthodontics were included. Study selection and data extraction were performed by two of the authors.ResultsA total of 3,923 articles were retrieved. After review of titles and abstracts, 41 articles were selected for full-text review and 25 articles were eligible for inclusion. Seven provided information on the WHO’s research cycle step 1 (“measuring harm”), twenty-one on “understanding causes” (step 2) and twelve on “identifying solutions” (step 3). No study provided information on Steps 4 and 5 (“evaluating impact” or “translating evidence into safer care”).ConclusionCurrent evidence on patient safety in orthodontics is scarce due to a lack of standardised reporting and probably also under-reporting of PSIs. Current literature on orthodontic patient safety deals primarily with “measuring harms” and “understanding causes of patient safety”, whereas less attention has been devoted to initiatives “identifying solutions”, “evaluating impact” and “translating evidence into safer care”. The present project holds a proposal for a new categorisation, terminology and future research agenda that may serve as a framework to support future research and clinical initiatives to improve patient safety in orthodontic care.RegistrationPROSPERO (CRD42022371982).

Sexual Safety in English mental health in-patient beds: has nothing been learned?

All mental health Trusts in England were surveyed, using freedom of Information Requests, as part of an enquiry into sexual safety incidents. A response rate of 72 % was obtained. Results revealed that sexual safety incidents and mixed-sex ward breaches are both increasing. Very few Trusts are adhering to the national guidance on sexual safety standards. Only one audit of safety standards was provided with full data. The Minister of Health has ordered an enquiry by the Health Services Safety Investigation Board with findings to be reported in 12 months’ time. We argue more urgent action is needed now.