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In 1994, quick response (QR) codes were developed by Denso Wave, a previous subsidiary company of Toyota, to track car components during manufacturing and distribution . Denso Wave holds the patent for QR codes but has made the technology widely available, free of cost. Since then, the use of these black-and-white pixelated squares has rapidly increased, due to their ability to contain more information than a standard bar code in a 10th of the space and their high-speed, omnidirectional scanning capabilities.
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Problems associated with implementation of QR codes for increasing engagement included: the requirement for internet access for full functionality [29, 42] and difficulties with downloading a QR code reader onto smartphones [40, 42].
Two studies discuss QR code application in combination with gamification to allow for the identification of a simulated patient or medication or in order to identify the user involved [21, 23]. Problems were identified with their use during these studies. These included difficulties with the QR code scanner reading the code during a game  and, as previously discussed, difficulties in co-ordinating a reliable internet connection and downloading a QR code scanner .
Although, some students or staff may have a lack of familiarity with QR codes, own a smartphone that can download a QR code reader, or own a smartphone at all, this is likely to change moving forwards. In 2018, 78% of the UK adult population owned a smartphone, up from 17% a decade earlier . The millennial generation are also establishing themselves in the healthcare environment with more competence and self-sufficiency with technology than their predecessors. Nonetheless, before smartphones become ubiquitous, it may lead to challenges by disadvantaging students and staff from certain socio-economic backgrounds and therefore affect their subsequent attainment.
HCAT is not only the first reliable tool for coding complaints, it is the first tool to measure the severity of complaints. It facilitates service monitoring and organisational learning and it enables future research examining whether healthcare complaints are a leading indicator of poor service outcomes. HCAT is freely available to download and use.
Resolving disagreements about how to apply HCAT to a specific healthcare complaint led us to the development of a set of guidelines for coding healthcare complaints (box 1). The final version of the HCAT, with all the severity indicators and guidelines, is freely available to download (see online supplementary file). Figure 2 demonstrates applying HCAT to illustrative excerpts.Box 1The guidelines for coding healthcare complaints with Healthcare Complaints Analysis ToolCoding should be based on empirically identifiable text, not on inferences.