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Original Investigation
April 2017

Families as Partners in Hospital Error and Adverse Event Surveillance

Author Affiliations
  • 1Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
  • 2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
  • 3Centre for Quality Improvement and Patient Safety, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
  • 4Center for Families, Boston Children’s Hospital, Boston, Massachusetts
  • 5Department of Nursing, Cardiovascular, and Critical Care Services, Boston Children’s Hospital, Boston, Massachusetts
  • 6Family-Centered Care, Lucile Packard Children’s Hospital, Palo Alto, California
  • 7Section of Critical Care, Department of Pediatrics, St Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
  • 8Section of Hospital Medicine, Department of Pediatrics, St Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
  • 9Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio
  • 10Department of Pediatrics, Benioff Children’s Hospital, University of California-San Francisco School of Medicine, San Francisco
  • 11Division of Pediatric Hospital Medicine, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California
  • 12Department of Pediatrics, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City
  • 13Department of Pediatrics, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
  • 14Department of Medicine, Harvard Medical School, Boston, Massachusetts
  • 15The Center for Patient Safety Research and Practice, Division of General Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 16Institute for Healthcare Delivery Research, Intermountain Healthcare, Salt Lake City, Utah
  • 17Section of General Pediatrics, Department of Pediatrics, St Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
  • 18Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Pediatr. 2017;171(4):372-381. doi:10.1001/jamapediatrics.2016.4812
Key Points

Question  How do rates of family-reported errors and adverse events (AEs) compare with those detected by other sources of hospital safety reporting that do not typically include families?

Findings  In this cohort study including 746 parents/caregivers of 989 hospitalized pediatric patients, families reported similar rates of errors and AEs as clinicians, and families reported 5-fold more errors and 3-fold more AEs than hospital incident reports. Including families in prospective systematic surveillance increased overall error detection rates by 16% and AE detection rates by 10%.

Meaning  Families provide unique safety information and have the potential to be valuable partners in safety surveillance conducted by both hospitals and researchers.

Abstract

Importance  Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection.

Objective  To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports.

Design, Setting, and Participants  We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient.

Main Outcomes and Measures  Error and AE rates.

Results  Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P =.006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.

Conclusions and Relevance  Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

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