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Outcomes of preterm infantsIn 2010, the Dutch practice regarding initiation of active treatment in extremely preterm infants was lowered from 25 buy cialis over the counter completed weeksâ to 24 completed weeksâ gestation. The Editorâs choice for this issue is the EPI-DAF study, reported by Pauline E van Beek and colleagues. The study provides contemporary population-based neurodevelopmental outcome data for all Dutch live-born infants, born between 240/7 weeksâ and 266/7 weeksâ gestational age, buy cialis over the counter who reached 2 yearsâ corrected age in 2018â2020. Assessments included medical history taking, physical and neurological examination, and assessment of mental and psychomotor development with the Dutch version of the Bayley Scales of Infant and Toddler Development (Bayley-III-NL). Parents filled out the Child Behavioural Checklist.

A combination of buy cialis over the counter medical history and results of the assessment was used to rate hearing and vision status. A composite outcome representing all these domains was classified as either moderate-to-severe impairment or mild or no impairment, based on the most severe individual component. 991 infants were live born at 24â26 completed weeksâ GA, of whom buy cialis over the counter 891 (90%) were admitted to a NICU. Of these, 651 (73%) infants survived and 587 (90%) were seen for follow-up at 2 years. Mortality (not admitted to NICU or died after NICU admission) was 58%, 31% and 21% at 24, 25, and 26 weeks' respectively.

Rates of moderate to severe NDI in any domain on follow-up were comparable (around 18% of survivors) between children born at 24 weeksâ, buy cialis over the counter 25 weeksâ and 26 weeksâ gestation. Lowering the threshold for supporting active treatment from 25 completed weeks to 24 completed weeks was not associated with a large increase in the number of survivors with moderate-severe neurodevelopmental impairment.In a separate study from Canada, Magdalena Jaworski and colleagues asked parents of infants born <29 weeksâ gestational age presenting at a neonatal follow-up clinic to evaluate their childrenâs health and development. 248 parents of 213 children (mean gestational age 26.6Â±1.6 weeks, 20% with severe neurodevelopmental buy cialis over the counter impairment) were recruited. Parents evaluated their childrenâs health at a median of 9/10. See pages F467 and F495Tactile stimulation during initial stabilisationNewborn infants get tactile stimulation to encourage them to breathe at birth but this does not necessarily continue once positive pressure ventilation is commenced.

Vincent Gaertner and colleagues analysed video and respiratory function monitor data gathered during a study of different face masks to report observational data on the buy cialis over the counter association between tactile stimulation and breathing patterns during positive pressure ventilation (PPV). 20 of 40 infants born >34 weeks' gestation received stimulation during PPV and this was associated with increased spontaneous breaths and increased exhaled tidal volume. Increased duration of stimulation and surface area of applied stimulus were associated with a larger buy cialis over the counter increase in spontaneous breaths. See page F508Associations of body composition with regional brain volumes in very preterm infantsKatherine Bell and colleagues performed MRI scans and air displacement plethysmography to determine body composition at term equivalent age in 85 preterm infants born <33 weeks gestation. Lean massâbut not fatâat term was associated with larger brain volume and white matter microstructure differences that suggest improved maturation.

Weight is a simplistic measure of overall nutrition and studies like buy cialis over the counter this, with later neurodevelopmental outcomes will help to refine our understanding of how to measure optimal nutrition for preterm infants. See page F533Effect of prophylactic dextrose gel on the neonatal gut microbiomeAs part of a placebo controlled randomised trial, Sophie St Claire and colleagues found no effect of orally administered glucose gel in the first hour after birth on the gut microbiome at 1,7, and 28 days. These data buy cialis over the counter should reassure parents and clinicians that use of dextrose gel in the newborn period will not have adverse consequences on the microbiome. See page F501Neonatal and fetal therapy of congenital diaphragmatic Hernia-related pulmonary hypertensionFelix De Bie and colleagues discuss clinically available neonatal and fetal therapies specifically targeting the pulmonary hypertension associated with congenital diaphragmatic hernia and review the most promising experimental treatments and future research avenues. See page F458Ethics statementsPatient consent for publicationNot applicable.Ethics approvalNot applicable..

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1330 G Street, NW, Washington, how to get cialis over the counter DC 20005 | Phone 202-347-5270 www.kff.org | Email Alerts. Kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/kff Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California..

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And many cialis super active of those who do go to rural areas donât stay long. Across the country, clinician complaints have historically landed on payment for services, but the problem goes far beyond money. Indeed, caring for patients during the cialis has drawn attention to quality of life, mental health, physical health, and safety issues.

During the cialis, hospital nurses, for example, have routinely worked long cialis super active hours to cover for sick colleagues, donned uncomfortable PPE, and been exposed to an unpredictable cialis. BPCâs April 2020 report, Confronting Rural Americaâs Health Care Crisis, demonstrates how workforce shortages can impact a communityâparticularly rural communities, which are especially hard hit by shortages. While urban areas have 53 primary care physicians for every 100,000 people, rural areas have only 40 primary care physicians to care for the same number of people.

The numbers are similar for cialis super active nurse practitioners, physician assistants, and dentists. For specialists, the discrepancy is alarming. While urban areas have 263 specialists per 100,000 people, rural areas struggle with only 30 specialists.

Part of the problem is cialis super active aging. Nearly one-third of primary care providers in rural areas were older than 56 in 2009. Because rural communities rely heavily on primary care clinicians, it is troublesome that only 12% of medical students are entering primary care residencies, and most of those graduates will not choose rural America as their home.

Fast forward to the cialis super active cialis. Rural hospital CEOs tell BPC that the nursing exodus is leaving them in dire straits. Many rural hospitals already experience year over year losses and even if they donât close, many are considering ceasing important services, such as obstetrics and maternal care, if they havenât already done so.

While some hospitals are already struggling to make ends meet, one rural hospital CEO indicated that the nursing shortage is costing them an additional $2 to $3 million a year because they must pay for travel nurses, which costs them two to three times more than staff nurses.Start Preamble National Telecommunications cialis super active and Information Administration, U.S. Department of Commerce. Start Printed Page 7824 Notice.

The National Telecommunications and Information Administration (NTIA) issues this Notice to initiate the annual process to seek expressions of interest from individuals who would like to serve on the Board of cialis super active the First Responder Network Authority (FirstNet Authority Board or Board). The term of one of the 12 non-permanent members to the FirstNet Authority Board will be available for appointment or reappointment in 2022. To be considered for the calendar year 2022 appointment, expressions of interest must be electronically transmitted on or before March 14, 2022.

Applicants should cialis super active submit expressions of interest as described below to. Michael Dame, Acting Associate Administrator, Office of Public Safety Communications, National Telecommunications and Information Administration, by email to FirstNetBoardApplicant@ntia.gov. Start Further Info Michael Dame, Acting Associate Administrator, Office of Public Safety Communications, National Telecommunications and Information Administration.

Mdame@ntia.gov. Please direct media inquiries to NTIA's Office of Public Affairs, (202) 482-7002. End Further Info End Preamble Start Supplemental Information I.

Background and Authority The Middle Class Tax Relief and Job Creation Act of 2012 (Act) created the First Responder Network Authority (FirstNet Authority) as an independent authority within NTIA. The Act charged the FirstNet Authority with ensuring the building, deployment, and operation of a nationwide, interoperable public safety broadband network, based on a single, national network architecture.[] The FirstNet Authority holds the single nationwide public safety license granted for wireless public safety broadband deployment. The FirstNet Authority Board is responsible for providing overall policy direction and oversight of FirstNet to ensure that the nationwide network continuously meets the needs of public safety.

II. Structure The FirstNet Authority Board is composed of 15 voting members. The Act names the Secretary of Homeland Security, the Attorney General of the United States, and the Director of the Office of Management and Budget as permanent members of the FirstNet Authority Board.

The Secretary of Commerce (Secretary) appoints the 12 non-permanent members of the FirstNet Authority Board.[] The Act requires each Board member to have experience or expertise in at least one of the following substantive areas. Public safety, network, technical, and/or financial.[] Additionally, the composition of the FirstNet Authority Board must satisfy the other requirements specified in the Act, including that. (i) At least three members have served as public safety professionals.

(ii) at least three members represent the collective interests of states, localities, tribes, and territories. And (iii) its members reflect geographic and regional, as well as rural and urban, representation.[] An individual Board member may satisfy more than one of these requirements. The current non-permanent FirstNet Authority Board members are (noting expiration of term).

Karima Holmes, Senior Director, ShotSpotter, Inc.. 911 professional (Term expires. August 2022) Board Chair Stephen Benjamin, Former Mayor, Columbia, SC (Term expires.

September 2024) Richard Carrizzo, Fire Chief, Southern Platte Fire Protection District, MO (Term expires. September 2024) Brian Crawford, SVP/Chief Administrative Officer for Willis-Knighton Health System and retired Fire Chief and Municipal Government Executive (Term expires. September 2024) Alexandra Fernandez Navarro, Former Associate Member, Puerto Rico Public Service Regulatory Board (Term expires.

September 2024) Kristin Graziano, Sheriff, Charleston County, SC (Term expires. September 2024) Billy Hewes, Mayor, Gulfport, MS (Term expires. September 2024) Peter Koutoujian, Sheriff, Middlesex County, MA (Term expires.

September 2024) Warren Mickens, Retired technology executive (Term expires. September 2024) Sylvia Moir, Retired Police Chief (Term expires. September 2024) Jocelyn Moore, Independent Director, DraftKings (Term expires.

September 2024) Paul Patrick, Division Director, Family Health and Preparedness, Utah Department of Health (Term expires. September 2024) Any Board member whose term has expired may serve until such member's successor has taken office, or until the end of the calendar year in which such member's term has expired, whichever is earlier.[] Board members will be appointed for a term of three years.[] Board members may not serve more than two consecutive full three-year terms.[] More information about the FirstNet Authority Board is available at www.firstnet.gov/âabout/âBoard. III.

Compensation and Status as Government Employees FirstNet Authority Board members are appointed as government employees. FirstNet Authority Board members are compensated at the daily rate of basic pay for level IV of the Executive Schedule (approximately $176,300 per year) for each day worked on the FirstNet Authority Board.[] Board members work intermittent schedules and may not work more than 130 days per year during their term. Each Board member must be a United States citizen, cannot be a registered lobbyist, and cannot be a registered agent of, employed by, or receive payments from, a foreign government.[] IV.

Financial Disclosure and Conflicts of Interest FirstNet Authority Board members must comply with certain federal conflict of interest statutes and ethics regulations, including some financial disclosure requirements. A FirstNet Authority Board member will generally be prohibited from participating on any particular FirstNet Authority matter that will have a direct and predictable effect on his or her personal financial interests or on the interests of the appointee's spouse, minor children, or non-federal employer. V.

Selection Process At the direction of the Secretary, NTIA will conduct outreach to the public safety community, state and local organizations, and industry to solicit nominations for candidates to the Board who satisfy the statutory requirements for membership. In addition, the Secretary, through NTIA, will accept expressions of interest from any Start Printed Page 7825 individual, or from any organization proposing a candidate who satisfies the statutory requirements for membership on the FirstNet Authority Board. To be considered for a calendar year 2022 appointment, expressions of interest must be electronically transmitted on or before March 14, 2022.

All parties submitting an expression of interest should submit the candidate's (i) full name, title, organization, address, telephone number, email address. (ii) current resume. (iii) brief bio.

The numbers are similar for nurse practitioners, physician assistants, and dentists buy cialis over the counter. For specialists, the discrepancy is alarming. While urban areas have 263 specialists per 100,000 people, rural areas struggle with only 30 specialists.

Part of the problem is buy cialis over the counter aging. Nearly one-third of primary care providers in rural areas were older than 56 in 2009. Because rural communities rely heavily on primary care clinicians, it is troublesome that only 12% of medical students are entering primary care residencies, and most of those graduates will not choose rural America as their home.

Fast forward to buy cialis over the counter the cialis. Rural hospital CEOs tell BPC that the nursing exodus is leaving them in dire straits. Many rural hospitals already experience year over year losses and even if they donât close, many are considering ceasing important services, such as obstetrics and maternal care, if they havenât already done so.

While some hospitals are already struggling to make ends meet, one rural hospital CEO indicated that the nursing shortage is costing them an additional $2 to $3 million a year because they must buy cialis over the counter pay for travel nurses, which costs them two to three times more than staff nurses.Start Preamble National Telecommunications and Information Administration, U.S. Department of Commerce. Start Printed Page 7824 Notice.

The National Telecommunications and Information Administration (NTIA) issues this Notice to initiate the annual process to seek expressions of interest from individuals who would like to serve on the buy cialis over the counter Board of the First Responder Network Authority (FirstNet Authority Board or Board). The term of one of the 12 non-permanent members to the FirstNet Authority Board will be available for appointment or reappointment in 2022. To be considered for the calendar year 2022 appointment, expressions of interest must be electronically transmitted on or before March 14, 2022.

Applicants should submit expressions of interest as described below buy cialis over the counter to. Michael Dame, Acting Associate Administrator, Office of Public Safety Communications, National Telecommunications and Information Administration, by email to FirstNetBoardApplicant@ntia.gov. Start Further Info Michael Dame, Acting Associate Administrator, Office of Public Safety Communications, National Telecommunications and Information Administration.

Mdame@ntia.gov. Please direct media inquiries to NTIA's Office of Public Affairs, (202) 482-7002. End Further Info End Preamble Start Supplemental Information I.

Karima Holmes, Senior Director, ShotSpotter, Inc.. 911 professional (Term expires. August 2022) Board Chair Stephen Benjamin, Former Mayor, Columbia, SC (Term expires.

All parties submitting an expression of interest should submit the candidate's (i) full name, title, organization, address, telephone number, email address. (ii) current resume. (iii) brief bio.

(iv) statement of qualifications that references how the candidate satisfies the Act's expertise, representational, and geographic requirements for FirstNet Authority Board membership, as described in this Notice. And (v) a statement describing why the candidate wants to serve on the FirstNet Authority Board, affirming their ability and availability to take a regular and active role in the Board's work. The Secretary will select FirstNet Authority Board candidates based on the eligibility requirements in the Act and recommendations submitted by NTIA.

NTIA will recommend candidates based on an assessment of qualifications as well as demonstrated ability to work in a collaborative way to achieve the goals and objectives of the FirstNet Authority as set forth in the Act. NTIA may consult with FirstNet Authority Board members or executives in making its recommendation. Board candidates will be vetted through the Department of Commerce and are subject to an appropriate background check for security clearance.

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Homelessness is a major public health challenge faced what does cialis do by many countries, and in many places, it has been aggravated by the economic downturn associated with the erectile dysfunction treatment cialis. Even in wealthy countries, homelessness remains a major social and public what does cialis do health issue. For example, in the USA, which is one of the wealthiest countries in the world, an estimated 600â000 individuals are homeless on any given night.1 Homelessness is defined as the lack of âa fixed, regular, and adequate night time residenceâ by the US Department of Housing and Urban Development.2 Studies have found that homeless individuals are more likely to encounter barriers to accessing medical care, including poverty, family problems, poor health literacy and a lack of social support.3 Homelessness is an especially important issue among young women, as pregnancy among homeless women is common and, due to the lack of resources available for homeless women, the health and lives of both mother and baby could be affected if appropriate care cannot be delivered.4 Due to the intersection of homelessness, poverty, drug use and limited access to effective contraception, homeless female adolescents are more likely to report a pregnancy in a lifetime than their housed counterparts.5 Homelessness may impact the health outcomes of pregnant women and their babies,6 and pregnancy may also increase womenâs risk of experiencing homelessness due to dropping out of school or surviving domestic violence related to pregnancy.7 8 Despite the critical importance of understanding the quality of care and outcomes of homeless women during pregnancy and delivery, research examining the health and healthcare access among postpartum homeless women has been limited.In this issue of BMJ Quality and Safety, Sakai-Bizmark and colleagues9 report the results of an observational study that analysed how rates of hospital revisits (ie, readmissions and emergency department (ED) visits) differ between postpartum homeless and housed women, using an administrative database of all hospitalisations and ED visits in New York state from 2009 to 2014. New York state has one of the highest numbers of homeless people in the nation, with 92â091 homeless individuals identified on a given night in 2019, accounting what does cialis do for more than 16% of total homelessness in the USA. From this state-wide database, 82â820 homeless postpartum what does cialis do women and 1â026â965 housed postpartum women were included.

The authors found that after adjusting for patient characteristics, including demographics and pregnancy/neonatal complications, homeless postpartum women were less likely to revisit hospitals within 6âweeks after hospital discharge. They also found that homeless women were less likely to be hospitalised or visit the ED after hospital discharge than the low-income housed population, who are more comparable with the homeless population in terms of socioeconomic background than the general (including higher-income) housed population.Unclear mechanisms for low revisit rates among homeless postpartum womenThe study did not investigate the underlying mechanisms explaining why hospital revisit what does cialis do rates after delivery were lower among homeless women compared with housed women. The authors discussed two possible explanations, but with very different interpretations regarding the quality of what does cialis do care9. (1) limited access to necessary hospital services among homeless women, suggesting a potential problem in the quality of care. (2) the protective effect of the respite and convalescent care that homeless women in New York state receive in homeless shelters what does cialis do after childbirth, suggesting possible directions to improve care for women with low incomes who do not have access to the same resources.

Although these two mechanisms have vastly different implications, the authors did not empirically examine the plausibility of these two hypotheses, so they could neither support nor refute the mechanisms. However, the authors were able to explore whether the lack of access to healthcare could explain their findings, since approximately 75% of homeless what does cialis do women had public insurance in this sample. Presumably, these women did not what does cialis do face the issue of limited access to postpartum healthcare. In the USA, it is recommended that women who have delivered a baby visit an obstetrician 2 or 3âweeks after delivery to follow up on physical recovery, emotional health and any special needs related to pregnancy. During such appointments, an obstetrician may identify health issues that what does cialis do would otherwise go undetected.

It is possible that homeless women generally have fewer interactions with what does cialis do healthcare providers, leading to missed opportunities to identify postpartum health issues. If this explanation is true, the low follow-up visit rate may be due to factors such as limited social support and childcare, low health literacy and lack of trust in healthcare providers. However, the what does cialis do administrative data used in the study were able to capture only events during mothersâ hospitalisations and ED visits, and therefore this study was unable to evaluate ambulatory follow-up visits after delivery. Similarly, due to the data limitation, the study could not address the quality of perinatal care and postpartum maternal or child health outcome other than hospital revisits.It is also possible that the respite and convalescent programmes at shelters provided to homeless women in New York was the major contributor of lower revisit rates among homeless patients found in this study, given the potential importance of post-delivery management in preventing readmissions among women with problematic deliveries and comorbidities.10 In fact, New York state has among the highest level of shelter use. The probability of homeless individuals what does cialis do using a shelter on a given night is more than 95% in New York, in contrast to less than 67% across the USA.11 If this were the main explanation of the studyâs findings, there would be a concern that the findings may not be generalisable to other states.

For example, this study reported that homeless women had lower crude rates of caesarean what does cialis do section and premature rupture of membranes (which are risks for readmission) than housed women in New York. However, in a recent study that used data from three states (Massachusetts and Florida as well as New York) to study similar research questions,12 these metrics were similar between homeless and housed women hospitalised for delivery. This suggests that New what does cialis do York may have unique features that enable homeless mothers to receive high-quality care that are unavailable in other states. More detailed research on postpartum support, patient satisfaction and clinical conditions (eg, maternal , depression, exacerbation of pre-existing what does cialis do conditions) between homeless and housed women, including studies in areas with different homeless policies and quality of maternal care for homeless mothers, should be able to clarify whether the findings from this study were unique to New York. Including the perspectives and experiences of these women themselves, rather than relying on administrative data, is likely to provide valuable additional insights.

Such research will require overcoming the difficulties in defining a representative homeless population, the reluctance to participate by the homeless individuals and the what does cialis do stigma of the homeless population by the research team.Should we adjust for socioeconomic factors in measuring quality indicators?. The study by Sakai-Bizmark et al 9 also contributes to the current discussion regarding whether postpartum hospital revisits can be used to measure the quality of perinatal care at hospitals.13 Recent studies suggest that postpartum readmission rates differ by race/ethnicity and insurance status,14 15 but it has also been reported that hospital-level variation is negligible.15 16 Given these findings, some may advocate the use of socioeconomic status (SES) in risk adjustment to use postpartum hospital revisit rates as a metric of the quality of maternal care. If SES reflects risk factors difficult for hospitals to address (patientsâ pre-existing clinical conditions and access to post-discharge care), simply using hospital revisit rates without accounting for SES may penalise hospitals what does cialis do that provide care to many patients with low SES.17 Conversely, critics of this position may be concerned that accounting for SES in risk adjustment would lead to acceptance of a lower quality of care for socially disadvantaged mothers. Adjusting for SES may mask the disparities in the quality what does cialis do of care by SES and allow hospitals not to take the measures required to reduce postpartum hospital revisits among such patient populations (such as discharge planning and connection to social welfare services).Similar discussions are ongoing in areas beyond maternal care. For example, in the USA, the Hospital Readmission Reduction Program (HRRP), initiated in 2013, penalises hospitals with high risk-adjusted 30-day readmission rates for some medical conditions and surgical procedures.18 This programme has been criticised for not accounting for SES in its risk adjustment model, given that individuals with lower SES generally have higher adjusted 30-day readmission rates than those in higher SES groups.19 To overcome this problem, the HRRP started to classify hospitals into five levels based on the percentage of patients with Medicaid dual-eligibility in 2019 following the implementation of the 21st Century Cures Act and compare hospital performance within each group of hospitals.20 Furthermore, regardless of whether adjusted for SES or not in the statistical model, presenting overall patient outcomes may obscure hospital-level variations in the quality of care for socially disadvantaged populations.

For example, even though a hospital looks good in terms of patient outcomes as a total, it does not necessarily mean that the quality of care for a socially disadvantaged population is good if the hospital has a low proportion what does cialis do of such a population. To âunmaskâ the healthcare disparities among socially disadvantaged populations, the National Quality what does cialis do Forum has proposed having each hospital present quality measures stratified by SES.17Here, it is important to note that SES can be measured in multiple ways, including income, educational attainment and Medicaid dual-eligibility status. Ultimately, which SES indicators should be considered and whether to adjust for them may be evaluated on a case-by-case basis, depending on the outcome measures and their empirical relationship with the SES indicators. The study by what does cialis do Sakai-Bizmark et al shed light on the potential importance of using housing status as an additional indicator of SES besides income related to postpartum hospital revisits. Future research is warranted to understand whether collecting information on housing status and presenting both risk-adjusted overall estimates and estimates stratified by housing status and other indicators of SES improves insight in overall quality of care delivered and also more specifically for underrepresented socioeconomic groups.ConclusionIt appears that homeless pregnant women who have delivered a baby experience fewer hospital readmissions and lower ED revisit rates than housed women in New York, which seemingly contradicts prior studies that suggested poorer health outcomes for homeless women.6 12 A better understanding of the reasons for this findingâwhether homeless pregnant women fare better than housed women or whether their health outcomes are just unobservedâis critically important to learn how to appropriately provide high-quality pregnancy and delivery care for homeless women.

Pregnant and postpartum homeless women what does cialis do are clearly among the most vulnerable groups in our society, and efforts should continue to shed light on their health problems and access to health and social services.Ethics statementsPatient consent for publicationNot required.In this issue of BMJ Quality &. Safety, Schnipper et al report the effects of a refined evidence-based toolkit and mentored implementation of a complex medication reconciliation intervention, âMARQUIS2â, at 18 North American hospitals.1 This pragmatic quality improvement study used interrupted time series analysis to quantify the effects of implementation on medication discrepancy rates relative to baseline what does cialis do trends. The MARQUIS2 toolkit was developed by refining the earlier MARQUIS1 toolkit, shown to be associated with a reduction in medication discrepancies but with inconsistent improvement among the five study sites.2 In brief, subsequent changes made to MARQUIS1 included (1) addition of simulated cases as training materials and to assess competency in taking a best possible medication history (BPMH), (2) greater use of pharmacy technicians to take BPMHs, (3) provision of advocacy aids, for example, return-on-investment calculators, to promote resourcing of medication reconciliation, (4) changes to electronic health recordsâ medication reconciliation functionality and (5) revision of patient/caregiver discharge education materials. The MARQUIS2 toolkit employed both system-level interventions, such as training staff to take a BPMH, and patient-level interventions, such as what does cialis do performing a BPMH. The study reported an increase in the number of system-level interventions adopted per site, an increase in the proportion of patients receiving patient-level interventions over time and a decrease in discrepancies per month what does cialis do over baseline trends.

The authors identified that delivery of system-level interventions alone was not associated with decreased discrepancy rates, while receipt of patient-level interventions alone was. The MARQUIS2 study findings therefore provide much-needed insights into what does cialis do the implementation of a medication reconciliation focused intervention across multiple sites. These findings also raise three important questions. Are patients currently involved in managing their own medication safety at care transitions, should they be and how or when might what does cialis do this be done?. There is evidence that the patient often has a passive and inexplicit role in transitional patient safety in general3 4 and transitional medication safety in particular,5 6 despite frequently wanting greater what does cialis do involvement.

Patients have been shown to be effective and willing actors in supporting their own transitional medication safety.7 For example, Fylan et al demonstrated that patients are an important source of system resilience following hospital discharge. They anticipate and identify medication errors, take preventative and corrective action to what does cialis do manage error and contribute to information management at various points.7 Additionally, the extent of the patientâs involvement in their own transitional safety is modifiable and influenced by their beliefs and perception of consequences3. Patients participate actively in handovers of care when they feel a need for involvement to ensure care continuity but are less active when they believe that their contribution is unnecessary or not appreciated.3 Such patient-led activities constitute medication work, a type of patient work that is an increasingly valued aspect of transitional medication safety.8 9 This is relevant to medication reconciliation because hospitalisation is associated with an increasing burden of potentially inappropriate prescribing, increasing medication regimen complexity and deprescribing of long-term medication.10 11 Holden and Abebe argue that medication what does cialis do changes, whether the addition of new medications or the deprescribing of established medications, are vulnerable periods for patients and add to their medication work burden.12 Therefore, the patientâs medication work burden at periods around care transitions merits attention. Although evidence suggests that patients currently have limited involvement in their own transitional medication safety, it also suggests that they ought to be supported to be more involved.Patient activation refers to a patientâs knowledge, skills and confidence in self-managing their own health.13 Patients who are more activated have better health outcomes and experience better care than those who are less activated, while those who are less activated are more likely to have unmet medical needs and to experience delays in care.13 Patient education and counselling, and patient follow-up postdischarge, have been identified as important patient-level interventions at care transitions contributing to reduced medication discrepancies14 15 and reduced healthcare utilisation.16 17 However, these activities represent behaviours delivered by professionals to patient/caregiver recipients and the extent to which they support patient activation or contribute to the patientâs medication work burden is unknown. Patient ergonomics, a field exploring the science and engineering of patient work, might therefore provide insights into opportunities to modify what does cialis do and nurture patient activation and opportunities for patient involvement in medication reconciliation.18The MARQUIS2 patient-level interventions, such as health coaching and patient counselling,1 were all delivered during the patientâs acute hospital stay.

The timing of intervention delivery warrants consideration, because a qualitative study of the hospital discharge process suggests that patients are suboptimally involved in discharge preparation and healthcare providers attempt to engage them at times when they are not receptive to this involvement, for example, on the day of discharge when patients may be pre-occupied with making preparations for returning home.6 Information provision and patient education should ideally be aligned with the patientâs or caregiverâs capacity to receive and engage with the information.9 It is possible that attempts to prepare people to be involved in managing their own medication safety at care transitions might be more effective if undertaken while the person is living well with chronic conditions in their own home rather than when they are acutely unwell and hospitalised. A systematic review of measurement tools in transitional patient safety identified several what does cialis do tools examining the patientâs perceived preparedness for hospital discharge, but none to assess this for hospital admission.19 Emergency hospital admission of community-dwelling adults is to some extent predictable, with polypharmacy as a key predictor.20 Therefore, future research could explore ways to involve patients in preparing for their own future care transitions before an emergency occurs.By its nature, medication safety at care transitions spans boundaries. It requires management of information about multiple patient what does cialis do interactions distributed across multiple systems, spaces and timepoints, as described above and depicted in figure 1. A work system is a construct of the interacting sociotechnical structural elements, such as people, tasks, tools and technologies, organisations and environments, of a body of work.8 The MARQUIS2 study explored medication reconciliation within the acute hospital work system.1 Calls have been made for a transitional medication safety focus that extends beyond any individual work system, such as the hospital work system or the primary care work system, because the patientâs medication management journey is distributed across time and space and therefore focusing on any one system is insufficient.8 9 18 19 To fully understand the patient journey and what leads to positive and negative consequences for transitional medication safety, future research could take a systems-based perspective across all relevant and interacting work systems.9 The Systems Engineering Initiative for Patient Safety (SEIPS) model provides a framework for integrating human factors/ergonomics in healthcare quality and patient safety improvement.21 A previous study of distributed healthcare tasks exemplifies application of the SEIPS model to medication management across the hospital-to-home transition.22 It demonstrates that a systems-based exploration can uncover a wide range of system boundary types including those between organisations, over time and professional-to-non-professional boundaries that would not have been observed with a narrower focus on a single work system. It also usefully uncovered details about the patientâs medication work system and what does cialis do its interaction with other work systems.

The third iteration of the SEIPS model, SEIPS 3.0, calls for a focus on the patientâs and caregiverâs journey over space and time as they interact with multiple elements and navigate the borders between them.21 SEIPS 3.0 therefore provides a helpful way to conduct a systems-based exploration of transitional medication safety that requires patient and public involvement (PPI), with an emphasis on patient ergonomics and the interactions between the patientâs medication work system and other relevant work systems.Patient medication work system situated within a system of interacting elements and work systems." data-icon-position data-hide-link-title="0">Figure 1 Patient medication work system situated within a system of what does cialis do interacting elements and work systems.The MARQUIS2 study sought to engage patient and family representatives in intervention development and evaluation by inviting them to contribute to developing discharge education and counselling materials and to be involved in all aspects of the research study.1 Additionally, community engagement and social marketing to patients as well as clinicians were among the system-level MARQUIS2 stakeholder involvement interventions. These are welcome examples of PPI in medication reconciliation, because there is mounting evidence that PPI enhances the quality, validity and impact of research and service development23 and yet PPI in medication reconciliation research is relatively rare and has not been described in systematic reviews examining the topic.14â17 Ocloo and Matthews argue for a move to meaningful and democratic inclusion of the relevant healthcare improvement patient population beyond what they described as the more prevalent tokenistic engagement of a narrow selection of PPI contributors.24 Although community engagement and social marketing were recommended MARQUIS2 system-level interventions, only 2 and 3 sites, respectively, of the 18 included study sites actually implemented these components with little detail on the nature of the PPI contributors or contributions to the overall research programme.1 Information about the facilitators and barriers to the adoption of community engagement and stakeholder involvement at individual study sites would therefore be instructive for those seeking to involve patients and the public in similar healthcare improvements. Articles describing PPI in medication safety research may offer helpful insights into how to conduct and report PPI, such as the types of engagement activities, the stages of the project when engagement might occur, the challenges encountered, the benefits realised and some general tips on supporting collaboration and partnership with patients and the public.25 26The report by Schnipper et what does cialis do al on the implementation and evaluation of the MARQUIS2 toolkit provides much-needed evidence to guide others seeking to implement medication reconciliation interventions at scale.1 It suggests either that patient-level interventions may be more important than system-level interventions, or that system-level interventions are necessary but not sufficient alone. Future transitional medication safety research could be further enhanced by exploring ways to promote patient involvement and activation in their own care, partnering with patient and caregiver stakeholders as members of the quality improvement and research teams and applying a systems-based exploration across the entire patient journey, inclusive of the patientâs medication work system and patient ergonomics.Ethics statementsPatient consent for publicationNot required..

Homelessness is a major public health challenge faced by many countries, and http://closelyknitphotography.com/high-fives/ in many buy cialis over the counter places, it has been aggravated by the economic downturn associated with the erectile dysfunction treatment cialis. Even in wealthy countries, homelessness remains a major social and buy cialis over the counter public health issue. For example, in the USA, which is one of the wealthiest countries in the world, an estimated 600â000 individuals are homeless on any given night.1 Homelessness is defined as the lack of âa fixed, regular, and adequate night time residenceâ by the US Department of Housing and Urban Development.2 Studies have found that homeless individuals are more likely to encounter barriers to accessing medical care, including poverty, family problems, poor health literacy and a lack of social support.3 Homelessness is an especially important issue among young women, as pregnancy among homeless women is common and, due to the lack of resources available for homeless women, the health and lives of both mother and baby could be affected if appropriate care cannot be delivered.4 Due to the intersection of homelessness, poverty, drug use and limited access to effective contraception, homeless female adolescents are more likely to report a pregnancy in a lifetime than their housed counterparts.5 Homelessness may impact the health outcomes of pregnant women and their babies,6 and pregnancy may also increase womenâs risk of experiencing homelessness due to dropping out of school or surviving domestic violence related to pregnancy.7 8 Despite the critical importance of understanding the quality of care and outcomes of homeless women during pregnancy and delivery, research examining the health and healthcare access among postpartum homeless women has been limited.In this issue of BMJ Quality and Safety, Sakai-Bizmark and colleagues9 report the results of an observational study that analysed how rates of hospital revisits (ie, readmissions and emergency department (ED) visits) differ between postpartum homeless and housed women, using an administrative database of all hospitalisations and ED visits in New York state from 2009 to 2014. New York state has one of the highest numbers of homeless people in the nation, with 92â091 homeless individuals buy cialis over the counter identified on a given night in 2019, accounting for more than 16% of total homelessness in the USA.

From this state-wide database, 82â820 homeless postpartum women and 1â026â965 housed postpartum women buy cialis over the counter were included. The authors found that after adjusting for patient characteristics, including demographics and pregnancy/neonatal complications, homeless postpartum women were less likely to revisit hospitals within 6âweeks after hospital discharge. They also buy cialis over the counter found that homeless women were less likely to be hospitalised or visit the ED after hospital discharge than the low-income housed population, who are more comparable with the homeless population in terms of socioeconomic background than the general (including higher-income) housed population.Unclear mechanisms for low revisit rates among homeless postpartum womenThe study did not investigate the underlying mechanisms explaining why hospital revisit rates after delivery were lower among homeless women compared with housed women. The authors discussed two possible explanations, but with very different interpretations regarding buy cialis over the counter the quality of care9.

(1) limited access to necessary hospital services among homeless women, suggesting a potential problem in the quality of care. (2) the protective effect of the respite and convalescent care that homeless women in New York state receive in homeless shelters after childbirth, suggesting possible directions to improve care for women with low incomes who do not have access buy cialis over the counter to the same resources. Although these two mechanisms have vastly different implications, the authors did not empirically examine the plausibility of these two hypotheses, so they could neither support nor refute the mechanisms. However, the authors were able to explore whether the lack of access to healthcare could explain their findings, since approximately 75% of homeless women had public insurance buy cialis over the counter in this sample.

Presumably, these women did not face the issue of limited access to buy cialis over the counter postpartum healthcare. In the USA, it is recommended that women who have delivered a baby visit an obstetrician 2 or 3âweeks after delivery to follow up on physical recovery, emotional health and any special needs related to pregnancy. During such appointments, an obstetrician buy cialis over the counter may identify health issues that would otherwise go undetected. It is possible that homeless women generally have buy cialis over the counter fewer interactions with healthcare providers, leading to missed opportunities to identify postpartum health issues.

If this explanation is true, the low follow-up visit rate may be due to factors such as limited social support and childcare, low health literacy and lack of trust in healthcare providers. However, the administrative data used in the study were buy cialis over the counter able to capture only events during mothersâ hospitalisations and ED visits, and therefore this study was unable to evaluate ambulatory follow-up visits after delivery. Similarly, due to the data limitation, the study could not address the quality of perinatal care and postpartum maternal or child health outcome other than hospital revisits.It is also possible that the respite and convalescent programmes at shelters provided to homeless women in New York was the major contributor of lower revisit rates among homeless patients found in this study, given the potential importance of post-delivery management in preventing readmissions among women with problematic deliveries and comorbidities.10 In fact, New York state has among the highest level of shelter use. The probability of homeless individuals using a shelter on a given night is more than 95% in New York, in contrast to less than 67% buy cialis over the counter across the USA.11 If this were the main explanation of the studyâs findings, there would be a concern that the findings may not be generalisable to other states.

For example, buy cialis over the counter this study reported that homeless women had lower crude rates of caesarean section and premature rupture of membranes (which are risks for readmission) than housed women in New York. However, in a recent study that used data from three states (Massachusetts and Florida as well as New York) to study similar research questions,12 these metrics were similar between homeless and housed women hospitalised for delivery. This suggests that New York may have unique features that enable homeless mothers buy cialis over the counter to receive high-quality care that are unavailable in other states. More detailed research on postpartum support, patient satisfaction and clinical conditions (eg, maternal , depression, exacerbation of pre-existing conditions) between homeless and housed women, including studies in areas with different buy cialis over the counter homeless policies and quality of maternal care for homeless mothers, should be able to clarify whether the findings from this study were unique to New York.

Including the perspectives and experiences of these women themselves, rather than relying on administrative data, is likely to provide valuable additional insights. Such research will require overcoming the difficulties in defining a representative homeless population, the reluctance to participate by the homeless individuals and the stigma of buy cialis over the counter the homeless population by the research team.Should we adjust for socioeconomic factors in measuring quality indicators?. The study by Sakai-Bizmark et al 9 also contributes to the current discussion regarding whether postpartum hospital revisits can be used to measure the quality of perinatal care at hospitals.13 Recent studies suggest that postpartum readmission rates differ by race/ethnicity and insurance status,14 15 but it has also been reported that hospital-level variation is negligible.15 16 Given these findings, some may advocate the use of socioeconomic status (SES) in risk adjustment to use postpartum hospital revisit rates as a metric of the quality of maternal care. If SES reflects risk factors buy cialis over the counter difficult for hospitals to address (patientsâ pre-existing clinical conditions and access to post-discharge care), simply using hospital revisit rates without accounting for SES may penalise hospitals that provide care to many patients with low SES.17 Conversely, critics of this position may be concerned that accounting for SES in risk adjustment would lead to acceptance of a lower quality of care for socially disadvantaged mothers.

Adjusting for SES may mask the disparities in the quality of care by SES and allow hospitals not to take the measures required to reduce postpartum hospital revisits among such patient populations (such buy cialis over the counter as discharge planning and connection to social welfare services).Similar discussions are ongoing in areas beyond maternal care. For example, in the USA, the Hospital Readmission Reduction Program (HRRP), initiated in 2013, penalises hospitals with high risk-adjusted 30-day readmission rates published here for some medical conditions and surgical procedures.18 This programme has been criticised for not accounting for SES in its risk adjustment model, given that individuals with lower SES generally have higher adjusted 30-day readmission rates than those in higher SES groups.19 To overcome this problem, the HRRP started to classify hospitals into five levels based on the percentage of patients with Medicaid dual-eligibility in 2019 following the implementation of the 21st Century Cures Act and compare hospital performance within each group of hospitals.20 Furthermore, regardless of whether adjusted for SES or not in the statistical model, presenting overall patient outcomes may obscure hospital-level variations in the quality of care for socially disadvantaged populations. For example, even though a buy cialis over the counter hospital looks good in terms of patient outcomes as a total, it does not necessarily mean that the quality of care for a socially disadvantaged population is good if the hospital has a low proportion of such a population. To âunmaskâ the healthcare disparities among socially disadvantaged populations, the National Quality Forum has proposed having each hospital present quality measures stratified by SES.17Here, buy cialis over the counter it is important to note that SES can be measured in multiple ways, including income, educational attainment and Medicaid dual-eligibility status.

Ultimately, which SES indicators should be considered and whether to adjust for them may be evaluated on a case-by-case basis, depending on the outcome measures and their empirical relationship with the SES indicators. The study by Sakai-Bizmark et al shed light on the potential importance of using housing status as an additional indicator buy cialis over the counter of SES besides income related to postpartum hospital revisits. Future research is warranted to understand whether collecting information on housing status and presenting both risk-adjusted overall estimates and estimates stratified by housing status and other indicators of SES improves insight in overall quality of care delivered and also more specifically for underrepresented socioeconomic groups.ConclusionIt appears that homeless pregnant women who have delivered a baby experience fewer hospital readmissions and lower ED revisit rates than housed women in New York, which seemingly contradicts prior studies that suggested poorer health outcomes for homeless women.6 12 A better understanding of the reasons for this findingâwhether homeless pregnant women fare better than housed women or whether their health outcomes are just unobservedâis critically important to learn how to appropriately provide high-quality pregnancy and delivery care for homeless women. Pregnant and postpartum homeless women are clearly among the most vulnerable groups in our society, and efforts should continue to shed light on their health problems and access to health and social services.Ethics statementsPatient consent for buy cialis over the counter publicationNot required.In this issue of BMJ Quality &.

Safety, Schnipper buy cialis over the counter et al report the effects of a refined evidence-based toolkit and mentored implementation of a complex medication reconciliation intervention, âMARQUIS2â, at 18 North American hospitals.1 This pragmatic quality improvement study used interrupted time series analysis to quantify the effects of implementation on medication discrepancy rates relative to baseline trends. The MARQUIS2 toolkit was developed by refining the earlier MARQUIS1 toolkit, shown to be associated with a reduction in medication discrepancies but with inconsistent improvement among the five study sites.2 In brief, subsequent changes made to MARQUIS1 included (1) addition of simulated cases as training materials and to assess competency in taking a best possible medication history (BPMH), (2) greater use of pharmacy technicians to take BPMHs, (3) provision of advocacy aids, for example, return-on-investment calculators, to promote resourcing of medication reconciliation, (4) changes to electronic health recordsâ medication reconciliation functionality and (5) revision of patient/caregiver discharge education materials. The MARQUIS2 toolkit employed both system-level buy cialis over the counter interventions, such as training staff to take a BPMH, and patient-level interventions, such as performing a BPMH. The study reported an increase in the number of system-level interventions adopted per site, an increase in the proportion of patients receiving patient-level interventions over buy cialis over the counter time and a decrease in discrepancies per month over baseline trends.

The authors identified that delivery of system-level interventions alone was not associated with decreased discrepancy rates, while receipt of patient-level interventions alone was. The MARQUIS2 study findings therefore provide much-needed insights into the implementation of a medication reconciliation focused intervention buy cialis over the counter across multiple sites. These findings also raise three important questions. Are patients currently involved in managing their own medication safety at care transitions, should they be and how or when might this be done? buy cialis over the counter.

There is buy cialis over the counter evidence that the patient often has a passive and inexplicit role in transitional patient safety in general3 4 and transitional medication safety in particular,5 6 despite frequently wanting greater involvement. Patients have been shown to be effective and willing actors in supporting their own transitional medication safety.7 For example, Fylan et al demonstrated that patients are an important source of system resilience following hospital discharge. They anticipate and identify medication errors, take preventative and corrective action to manage error and contribute to information management at various points.7 Additionally, the extent of the patientâs involvement in their own transitional safety is modifiable and influenced by buy cialis over the counter their beliefs and perception of consequences3. Patients participate actively in handovers of care when they feel a need for involvement to ensure care continuity but are less active when they believe that their contribution is unnecessary or not appreciated.3 Such patient-led activities constitute medication work, a type of patient work that is an increasingly valued aspect of transitional medication safety.8 9 This is relevant to medication reconciliation because hospitalisation is associated with buy cialis over the counter an increasing burden of potentially inappropriate prescribing, increasing medication regimen complexity and deprescribing of long-term medication.10 11 Holden and Abebe argue that medication changes, whether the addition of new medications or the deprescribing of established medications, are vulnerable periods for patients and add to their medication work burden.12 Therefore, the patientâs medication work burden at periods around care transitions merits attention.

Although evidence suggests that patients currently have limited involvement in their own transitional medication safety, it also suggests that they ought to be supported to be more involved.Patient activation refers to a patientâs knowledge, skills and confidence in self-managing their own health.13 Patients who are more activated have better health outcomes and experience better care than those who are less activated, while those who are less activated are more likely to have unmet medical needs and to experience delays in care.13 Patient education and counselling, and patient follow-up postdischarge, have been identified as important patient-level interventions at care transitions contributing to reduced medication discrepancies14 15 and reduced healthcare utilisation.16 17 However, these activities represent behaviours delivered by professionals to patient/caregiver recipients and the extent to which they support patient activation or contribute to the patientâs medication work burden is unknown. Patient ergonomics, a field exploring the science and engineering of patient work, might therefore provide insights into opportunities to modify and nurture patient activation and opportunities for patient involvement in medication reconciliation.18The MARQUIS2 patient-level interventions, such as health coaching and patient counselling,1 were all buy cialis over the counter delivered during the patientâs acute hospital stay. The timing of intervention delivery warrants consideration, because a qualitative study of the hospital discharge process suggests that patients are suboptimally involved in discharge preparation and healthcare providers attempt to engage them at times when they are not receptive to this involvement, for example, on the day of discharge when patients may be pre-occupied with making preparations for returning home.6 Information provision and patient education should ideally be aligned with the patientâs or caregiverâs capacity to receive and engage with the information.9 It is possible that attempts to prepare people to be involved in managing their own medication safety at care transitions might be more effective if undertaken while the person is living well with chronic conditions in their own home rather than when they are acutely unwell and hospitalised. A systematic review of measurement tools in transitional patient safety identified several tools examining the patientâs perceived preparedness for hospital discharge, but none to assess this for hospital admission.19 Emergency hospital admission of community-dwelling adults is to some extent predictable, with polypharmacy as a buy cialis over the counter key predictor.20 Therefore, future research could explore ways to involve patients in preparing for their own future care transitions before an emergency occurs.By its nature, medication safety at care transitions spans boundaries.

It requires management of information about multiple patient interactions distributed across multiple systems, spaces buy cialis over the counter and timepoints, as described above and depicted in figure 1. A work system is a construct of the interacting sociotechnical structural elements, such as people, tasks, tools and technologies, organisations and environments, of a body of work.8 The MARQUIS2 study explored medication reconciliation within the acute hospital work system.1 Calls have been made for a transitional medication safety focus that extends beyond any individual work system, such as the hospital work system or the primary care work system, because the patientâs medication management journey is distributed across time and space and therefore focusing on any one system is insufficient.8 9 18 19 To fully understand the patient journey and what leads to positive and negative consequences for transitional medication safety, future research could take a systems-based perspective across all relevant and interacting work systems.9 The Systems Engineering Initiative for Patient Safety (SEIPS) model provides a framework for integrating human factors/ergonomics in healthcare quality and patient safety improvement.21 A previous study of distributed healthcare tasks exemplifies application of the SEIPS model to medication management across the hospital-to-home transition.22 It demonstrates that a systems-based exploration can uncover a wide range of system boundary types including those between organisations, over time and professional-to-non-professional boundaries that would not have been observed with a narrower focus on a single work system. It also usefully uncovered details about the patientâs buy cialis over the counter medication work system and its interaction with other work systems. The third iteration of the SEIPS model, SEIPS 3.0, calls for a focus on the patientâs and caregiverâs journey over space and time as they interact with multiple elements and navigate the borders between them.21 SEIPS 3.0 therefore provides a helpful way to conduct a systems-based exploration of transitional medication safety that requires patient and public involvement (PPI), with an emphasis on patient ergonomics and the interactions between the patientâs medication work system and other relevant buy cialis over the counter work systems.Patient medication work system situated within a system of interacting elements and work systems." data-icon-position data-hide-link-title="0">Figure 1 Patient medication work system situated within a system of interacting elements and work systems.The MARQUIS2 study sought to engage patient and family representatives in intervention development and evaluation by inviting them to contribute to developing discharge education and counselling materials and to be involved in all aspects of the research study.1 Additionally, community engagement and social marketing to patients as well as clinicians were among the system-level MARQUIS2 stakeholder involvement interventions.

These are welcome examples of PPI in medication reconciliation, because there is mounting evidence that PPI enhances the quality, validity and impact of research and service development23 and yet PPI in medication reconciliation research is relatively rare and has not been described in systematic reviews examining the topic.14â17 Ocloo and Matthews argue for a move to meaningful and democratic inclusion of the relevant healthcare improvement patient population beyond what they described as the more prevalent tokenistic engagement of a narrow selection of PPI contributors.24 Although community engagement and social marketing were recommended MARQUIS2 system-level interventions, only 2 and 3 sites, respectively, of the 18 included study sites actually implemented these components with little detail on the nature of the PPI contributors or contributions to the overall research programme.1 Information about the facilitators and barriers to the adoption of community engagement and stakeholder involvement at individual study sites would therefore be instructive for those seeking to involve patients and the public in similar healthcare improvements. Articles describing PPI in medication safety research may offer helpful insights into how to conduct and report PPI, such as the types of engagement activities, the stages of the project when engagement might occur, the challenges encountered, the benefits realised and some general tips on supporting collaboration and partnership buy cialis over the counter with patients and the public.25 26The report by Schnipper et al on the implementation and evaluation of the MARQUIS2 toolkit provides much-needed evidence to guide others seeking to implement medication reconciliation interventions at scale.1 It suggests either that patient-level interventions may be more important than system-level interventions, or that system-level interventions are necessary but not sufficient alone. Future transitional medication safety research could be further enhanced by exploring ways to promote patient involvement and activation in their own care, partnering with patient and caregiver stakeholders as members of the quality improvement and research teams and applying a systems-based exploration across the entire patient journey, inclusive of the patientâs medication work system and patient ergonomics.Ethics statementsPatient consent for publicationNot required..

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