Interventions to improve handoff communications between health care providers are associated with improved patient safety. The association between safety and interventions to improve communication between health care providers and patients and families is poorly understood, particularly in pediatrics.
To determine if medical errors and adverse events (AEs) (primary outcomes), family experience, family and nurse engagement, and communication processes between health care providers and pediatric patients and families improve following implementation of a structured communication intervention (Patient- and Family-Centered I-PASS).
We conducted a prospective multicenter study of a patient and family-centered communication intervention, “Patient- and Family-Centered I-PASS,” implemented in a staggered fashion at 7 North American pediatric hospitals from December 2014-January 2017. The intervention included a health literacy-informed, structured communication framework for family-centered rounds (multidisciplinary bedside rounds that include families and integrate their perspectives into clinical decision-making); written rounds summaries for families; a staff training and learning program; and strategies to support teamwork and implementation. The primary outcome had 2 principal components: medical errors (ie, failures in care processes) and AEs (ie, harms to patients due to medical care). Rates of errors and AEs were measured using an established systematic surveillance methodology including family safety reporting. Family experience was measured through predischarge surveys. Communication processes (eg, family engagement, rounds duration, teaching on rounds) were assessed by means of direct observation. We used Poisson regression and generalized estimating equations clustered by site to compare pre- vs postimplementation data. To inform the development of a reliable safety surveillance methodology incorporating patient/family input, we also conducted a subpopulation analysis of the first 4 study sites in the preintervention cohort to compare rates of errors/AEs: (1) gathered systematically with vs without family reporting, (2) reported by families vs providers, and (3) reported by families vs hospital incident reports.
: Of a total 3106 patient admissions, the mean patient age was 7.1 years; 50.5% were female, 50.4% were non-White, and 8.0% had ≥2 complex chronic conditions (CCC). For parents, mean age was 36.2 years; 80.8% were female, 53.1% were non-White, most attended college, and roughly half reported annual household incomes <$50 000. : Harmful errors (preventable AEs) decreased 37.9% (20.7 vs 12.9 per 1000 patient-days, = .01) and overall AEs decreased 45.6% (34.0 vs 18.5, = .002) following intervention implementation. The rate of overall medical errors did not change. Top-box (choosing the top-most response on a scale; eg, “excellent”) ratings for 6 out of 25 components of family-reported experience improved; none worsened. The percentages of rounds observations with top-box rated family engagement (55.6% vs 66.7%, = .04) and nurse engagement (20.4% vs 35.5%, = .03) scores on rounds improved. The percentages of families expressing concerns at start of rounds (18.3% vs 42.0%, = .02) and reading back plans (11.8% vs 32.4%, = .04) increased. Observed teaching on rounds (73.4% of rounding encounters vs 72.4%, = .78) and rounds duration (8.5 vs 10.2 minutes per patient, = .13), as well as shared understanding between parent, nurse, and physicians, remained unchanged. : Error rates in our preintervention only subpopulation analysis of the first 4 study sites were higher with family reporting than without (45.9 vs 39.7, < .001), as were rates of AEs (28.7 vs 26.1, = .003). Family-reported incident rates (errors, AEs) were similar to those of providers ( > .05 for both) and 5.0 times ( = .009; errors) and 2.9 times ( = .02; AEs) higher than those from hospital incident reports. More educated parents and parents of CCC had higher rates of family-reported errors.
Implementation of a structured family-centered communication intervention was associated with improvements in patient safety, family experience, and multiple aspects of hospital communication processes, without negatively impacting teaching or rounds duration. Moreover, families provided unique information about hospital safety. Including families in hospital safety and communication has the potential to improve hospital safety and quality of care.
