Footnotes

• Competing interests KGS is the Editor-in-Chief of BMJ Quality & Safety.

• Provenance and peer review Commissioned; internally peer reviewed.

• ↵i A medical directive is an order given in advance by physicians (or others authorised to write orders) to enable a qualified health professional (typically a nurse) to decide to apply the order under specific conditions without a direct assessment by the physician at the time.8For instance, a medical directive might authorise for triage nurses in the ED to obtain an ECG on a patient with chest pain without waiting for a physician to enter a direct order.