After a cluster of perinatal deaths was identified in 2015, the authors assessed 15-years of routinely collected observational data from 7 different sources (administrative, patient complaint and legal data) preceding the cluster to determine whether the incidents could have been predicted and prevented. The extent of clinical activity along with direct-to-service patient complaints were found to be the more promising for purposes of potential predictive signals. The authors suggest that use of some routinely collected data of these types show promise; however, further work needs to be done on specificity and sensitivity of the data and to gain access to comparator data is needed.

Many institutions are encouraging patient and family engagement in safety initiatives. Prior research has shown that allowing parents to report safety concerns may help identify errors. In this study, investigators surveyed 170 parents at the time of their child's admission to the hospital to determine their desire to watch over the care provided. At discharge, parents were surveyed about medications and hand hygiene. They found that parents who wanted to watch over their child were more likely to question providers about medication use. The authors suggest that there may be additional opportunities for engaging such parents to improve safety. A past PSNet perspective discussed patient engagement and patient safety.

Family-centered rounding is a key patient engagement strategy for hospitalized children. In this cluster-randomized trial that included nearly 300 families, 2 pediatric inpatient services implemented a checklist to promote family-centered rounding and 2 services provided usual care. Through observation of video-recordings, investigators determined that teams who were given a checklist were more likely to ask families if they had questions and to read back provider orders for confirmation. Although families' perceptions of safety climate improved with checklist implementation, overall quality and safety ratings between the checklist and usual care groups were similar. This trial provides evidence that performing certain elements of the checklist, such as read back, can modestly enhance patient and family engagement.

This observational study found that more than half of parents of hospitalized children initiated conversations about medications during family-centered rounds. Common topics included scheduling (i.e., frequency or duration) or adverse drug reactions. These results underscore the importance of patient engagement in medication use and safety.

This focus group study used a systems engineering approach to identify methods to improve patient and family engagement in daily rounds at a pediatric hospital.

Patients can play an important role in ensuring their own safety during medical care. Hospitals have begun to engage patients in establishing a safety culture, and The Joint Commission's Speak Up initiative aims to empower patients to address potential safety hazards. In this study, parents of hospitalized children were given an adapted version of the AHRQ Hospital Survey on Patient Safety Culture, and 39% felt they "needed to watch over care" delivered to their children in order to avoid mistakes. The parent data fit well with previously validated domains of patient safety, and the authors suggest that such measurement could help advance a more patient-centered approach to improving safety climate. A recent AHRQ WebM&M perspective by Dr. Saul Weingart discussed the role of patient engagement in safety.

Voluntary error reporting systems are perhaps the most controversial of the available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This consensus conference, sponsored by the World Alliance for Patient Safety, drew together an international group of error reporting experts in order to develop a learning community for incident reporting. The ultimate goal was to develop guidelines for effective use of reporting systems to improve safety. Discussing the advantages and challenges of current reporting systems, this article proposes guidelines for maximizing incident reporting utility (based on a previously published framework). A previous article discussed the use of different types of reporting systems to obtain a comprehensive view of patient safety within an institution.

Voluntary error reporting systems are ubiquitous in health care, but such incident reports often fail to result in lasting safety improvements. Prior studies have shown that most hospitals do not have robust mechanisms for analyzing and learning from reported errors, and voluntarily reported errors may represent only a narrow part of all errors. In this study, the authors developed a statistical model to analyze incident reporting data to identify work areas with safety problems and rank the severity of safety problems identified. The model was validated using data from the National Reporting and Learning System. This model, once further validated, could greatly aid large organizations in using incident reporting data to improve safety.