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IntroductionPaediatric concussion is a common injury. Approximately 30% of youth with concussion will experience persisting postconcussion symptoms (PPCS) extending at least 1 month following injury. Recently, studies have shown the benefit of early, active, targeted therapeutic strategies. However, these are primarily prescribed from the specialty setting. Early access to concussion specialty care has been shown to improve recovery times for those at risk for persisting symptoms, but there are disparities in which youth are able to access such care. Mobile health (mHealth) technology has the potential to improve access to concussion specialists. This trial will evaluate the feasibility of a mHealth remote patient monitoring (RPM)-based care handoff model to facilitate access to specialty care, and the effectiveness of the handoff model in reducing the incidence of PPCS.Methods and analysisThis study is a non-randomised type I, hybrid implementation-effectiveness trial. Youth with concussion ages 13–18 will be enrolled from the emergency department of a large paediatric healthcare network. Patients deemed a moderate-to-high risk for PPCS using the predicting and preventing postconcussive problems in paediatrics (5P) stratification tool will be registered for a web-based chat platform that uses RPM to collect information on symptoms and activity. Those patients with escalating or plateauing symptoms will be contacted for a specialty visit using data collected from RPM to guide management. The primary effectiveness outcome will be the incidence of PPCS, defined as at least three concussion-related symptoms above baseline at 28 days following injury. Secondary effectiveness outcomes will include the number of days until return to preinjury symptom score, clearance for full activity and return to school without accommodations. The primary implementation outcome will be fidelity, defined as the per cent of patients meeting specialty care referral criteria who are ultimately seen in concussion specialty care. Secondary implementation outcomes will include patient-defined and clinician-defined appropriateness and acceptability.Ethics and disseminationThis study was approved by the Institutional Review Board of the Children’s Hospital of Philadelphia (IRB 22-019755). Study findings will be published in peer-reviewed journals and disseminated at national and international meetings.Trial registration number NCT05741411.

Background Motor vehicle crashes and resultant fatalities remain disproportionately high among young drivers, with crash risk peaking immediately after licensure. Although graduated driver licensing laws (GDL) for young novice drivers have reduced such fatalities, driver error remains a leading cause; thus, prevention efforts that target improving skills in novice teen drivers before licensure are a strong candidate for reducing crash risk early in licensure. States with more comprehensive driver licensing laws that include mandated driver training before licensure in addition to GDL show lower crash rates post-licensure, but these effects were not determined through rigorous controlled studies of driver training. This paper describes the DRIVER study, a phase III randomized trial that tests the effectiveness of two different driver training programs in reducing young driver crash risk early in licensure in Pennsylvania, a state like many others that does not require formal training for young drivers. Methods Learner drivers age 16 and 17 years will be recruited and followed through the GDL learner phase and for six months post-licensure. Participants will be randomly assigned to one of three interventions: professional behind-the-wheel training (n = 333), online hazard training (n = 333), or an active control online vehicle and driver safety course, unrelated to hazard skills training (n = 333). The primary outcomes are on-road crash risk post-licensure (via kinematic hard braking events tracked through a smartphone-based app) and state license examination performance. Secondary outcomes include change in simulated driving performance from baseline to the time of license examination, self-reported and kinematically tracked risky driving behavior (e.g. cell phone use, speeding) and self-reported crashes. Participants will complete baseline surveys and cognitive assessments to determine potential moderating effects of cognitive maturation and risk-taking tendencies. Discussion Findings from the DRIVER study will provide insights into training effectiveness generally, and an evidence base for recommendations to policy makers, while also revealing for whom these interventions are less effective. Trial registration The study was registered on ClinicalTrials.gov Registry (NCT06413927) in May 2024, https://clinicaltrials.gov/study/NCT06413927 and last updated on August 11th, 2025. This protocol was developed per the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) Checklist. Key Message What is already known: States with more comprehensive driver licensing laws that include mandated behind-the-wheel (BTW) driver training before licensure in addition to GDL show lower crash rates post-licensure, but these effects were not determined through rigorous controlled studies of driver training and there may be barriers to accessing BTW training. What this study adds: This Phase III randomized trial will test the effectiveness of BTW driver training and an evidence-based online virtual hazard skills training in reducing young driver crash risk early in licensure. How this study might affect research, practice or policy: Findings will provide insights into training effectiveness overall, and an evidence base for recommendations to policy makers, while also advancing research by identifying individual characteristics that determine for whom each type of training is not effective, addressing key gaps in understanding individual differences in training outcomes.

Motor vehicle crashes remain a leading cause of injury and death in adolescents, with teen drivers three times more likely to be in a fatal crash when compared to adults. One potential contributing risk factor is the ongoing development of executive functioning with maturation of the frontal lobe through adolescence and into early adulthood. Atypical development resulting in poor or impaired executive functioning (as in Attention-Deficit/Hyperactivity Disorder) has been associated with risky driving and crash outcomes. However, executive function broadly encompasses a number of capacities and domains (e.g., working memory, inhibition, set-shifting). In this review, we examine the role of various executive function sub-processes in adolescent driver behavior and crash rates. We summarize the state of methods for measuring executive control and driving outcomes and highlight the great heterogeneity in tools with seemingly contradictory findings. Lastly, we offer some suggestions for improved methods and practical ways to compensate for the effects of poor executive function (such as in-vehicle assisted driving devices). Given the key role that executive function plays in safe driving, this review points to an urgent need for systematic research to inform development of more effective training and interventions for safe driving among adolescents.

Motor vehicle crashes remain the leading cause of adolescent mortality and injury in the United States. For young drivers, crash risk peaks immediately after licensure and declines during the next two years, making the point of licensure an important safety intervention opportunity. Legislation in Ohio established a unique healthtransportation partnership among the State of Ohio, Children's Hospital of Philadelphia, and Diagnostic Driving, Inc., to identify underprepared driver license applicants through a virtual driving assessment system. The system, a computer-based virtual driving test, exposes drivers to common serious crash scenarios to identify critical skill deficits and is delivered in testing centers immediately before the on-road examination. A pilot study of license applicants who completed it showed that the virtual driving assessment system accurately predicted which drivers would fail the onroad examination and provided automated feedback that informed drivers on their skill deficits. At this time, the partnership's work is informing policy changes around integrating the virtual driving assessment system into licensing and driver training with the aim of reducing crashes in the first months of independent driving. The system can be developed to identify deficits in safety-critical skills that lead to crashes in new drivers and to address challenges that the coronavirus disease 2019 pandemic has introduced to driver testing and training.

Background Like most hospitals, our hospital experienced COVID-19 pandemic-related supply chain shortages. Our additive manufacturing lab’s capacity to offset these shortages was soon overwhelmed, leading to a need to improve the efficiency of our existing workflow. We undertook a work system analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) construct which is based on human factors and quality improvement principles. Our objective was to understand the inefficiencies in project submission, review, and acceptance decisions, and make systematic improvements to optimize lab operations. Methods Contextual inquiry (interviews and workflow analysis) revealed suboptimal characteristics of the system, specifically, reliance on a single person to facilitate work and, at times, fractured communication with project sponsors, with root causes related to the project intake and evaluation process as identified through SEIPS tools. As interventions, the analysis led us to: 1) enhance an existing but underused project submission form, 2) design and implement an internal project scorecard to standardize evaluation of requests, and 3) distribute the responsibility of submission evaluation across lab members. We implemented these interventions in May 2021 for new projects and compare them to our baseline February 1, 2018 through – April 30, 2021 performance (1184 days). Results All project requests were submitted using the enhanced project submission form and all received a standardized evaluation with the project scorecard. Prior to interventions, we completed 35/79 (44%) of projects, compared to 12/20 (60%) of projects after interventions were implemented. Time to review new submissions was reduced from an average of 58 days to 4 days. A more distributed team responsibility structure permitted improved workflow with no increase in staffing, allowing the Lab Manager to devote more time to engineering rather than administrative/decision tasks. Conclusions By optimizing our workflows utilizing a human factors approach, we improved the work system of our additive manufacturing lab to be responsive to the urgent needs of the pandemic. The current workflow provides insights for labs aiming to meet the growing demand for point-of-care manufacturing.

Driving evaluations aim to ensure adequate skills; however, feedback beyond pass/fail is needed for improvement. Therefore, the goal of this study was to inform driving feedback report design to ensure ease of use and understandability while motivating improvements. Participants ages 18–25 years (n = 521) were recruited from CloudResearch Prime Panels to rate one of nine report design conditions with various combinations of five key features: performance summary presence, action plan (AP) length, AP order, AP grading system, and peer comparison presence; they then completed questionnaires. Participants were more motivated to improve when a summary was present (p = 0.02); they rated reports easier to use if they had a long AP (p = 0.01), a short AP paired with a summary (p = 0.007), or an AP with a number grade (p = 0.016); and they rated reports easier to understand if they had a short AP (p = 0.002) or an AP ordered by worst-to-best performance (p = 0.05). These results suggest that feedback reports designed with a performance summary and short, targeted action plan starting with the biggest area for improvement are likely to motivate action to improve driving skills while being easy to use and understand. Future research should evaluate the effect of such a redesigned report on driving outcomes among young drivers.

Magnetoencephalography (MEG) is particularly well‐suited to the study of human motor cortex oscillatory rhythms and motor control. However, the motor tasks studied to date are largely overly simplistic. This study describes a new approach: a novel event‐based simulated drive made operational via MEG compatible driving simulator hardware, paired with differential beamformer methods to characterize the neural correlates of realistic, complex motor activity. We scanned 23 healthy individuals aged 16–23 years (mean age = 19.5, SD = 2.5; 18 males and 5 females, all right‐handed) who completed a custom‐built repeated trials driving scenario. MEG data were recorded with a 275‐channel CTF, and a volumetric magnetic resonance imaging scan was used for MEG source localization. To validate this paradigm, we hypothesized that pedal‐use would elicit expected modulation of primary motor responses beta‐event‐related desynchronization (B‐ERD) and movement‐related gamma synchrony (MRGS). To confirm the added utility of this paradigm, we hypothesized that the driving task could also probe frontal cognitive control responses (specifically, frontal midline theta [FMT]). Three of 23 participants were removed due to excess head motion (>1.5 cm/trial), confirming feasibility. Nonparametric group analysis revealed significant regions of pedal‐use related B‐ERD activity (at left precentral foot area, as well as bilateral superior parietal lobe: p < .01 corrected), MRGS (at medial precentral gyrus: p < .01 corrected), and FMT band activity sustained around planned braking (at bilateral superior frontal gyrus: p < .01 corrected). This paradigm overcomes the limits of previous efforts by allowing for characterization of the neural correlates of realistic, complex motor activity in terms of brain regions, frequency bands and their dynamic temporal interplay. This study describes a new approach: a novel event‐based simulated drive made operational via magnetoencephalography compatible driving simulator hardware, paired with differential beamformer methods to characterize the neural correlates of realistic, complex motor activity. This paradigm is validated by expected primary beta and gamma motor responses. Demonstrating added utility, increased task demands were revealed in frontal midline theta cognitive control activity, and motor cortex gamma power decreased with habituation/learning over trials.

This study examines whether cell phone use stands apart from a general pattern of risky driving practices associated with crashes and impulsivity-related personality traits in young drivers. A retrospective online survey study recruited 384 young drivers from across the United States using Amazon’s Mechanical Turk to complete a survey measuring risky driving practices (including cell phone use), history of crashes, and impulsivity-related personality traits. Almost half (44.5%) of the drivers reported being involved in at least one crash, and the majority engaged in cell phone use while driving (up to 73%). Factor analysis and structural equation modeling found that cell phone use loaded highly on a latent factor with other risky driving practices that were associated with prior crashes (b = 0.15, [95% CI: 0.01, 0.29]). There was also an indirect relationship between one form of impulsivity and crashes through risky driving (b = 0.127, [95% CI: 0.01, 0.30]). Additional analyses did not find an independent contribution to crashes for frequent cell phone use. These results suggest a pattern of risky driving practices associated with impulsivity in young drivers, indicating the benefit of exploring a more comprehensive safe driving strategy that includes the avoidance of cell phone use as well as other risky practices, particularly for young drivers with greater impulsive tendencies.