Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Dinnen T, Williams H, Yardley S, et al. BMJ Support Palliat Care. 2019.
Advance care planning (ACP) allows patients to express and document their preferences about medical treatment; however, there are concerns about uptake and documentation due to human error. This study used patient safety incident reports in the UK to characterize and explore safety issues arising from ACP and to identify areas for improvement. Over a ten-year period, there were 70 reports of an ACP-related patient safety incident (due to incomplete documentation, inaccessible documentation or miscommunication, or ACP directives not being followed) which led to inappropriate treatment, transfer or admission. The importance of targeting the human factors of the ACP process to improve safety is discussed. A PSNet Human Factors Primer on human factors expands on these concepts.
Fitzsimons BT, Fitzsimons LL, Sun LR. Pediatrics. 2019;143:e20183458.
Rare diseases pose diagnostic challenges for physicians. This commentary offers insights from parents of a young child who died due to a delayed stroke diagnosis as well as from the patient's neurologist to raise awareness of childhood stroke and discuss the importance of partnership to heal from loss and advocate for improvement.
Implementing new information systems can have unintended consequences on processes. This commentary explores insights from a physician, both as a clinician and as the family member of a patient, regarding the impact of hard stops in electronic health records intended to prevent gaps in data entry prior to task progression. The author raises awareness of the potential for patient harm due to interruptions and diminishing student and clinician skill in asking questions to build effective patient histories.
Bell SK, Roche SD, Mueller A, et al. BMJ Qual Saf. 2018;27:928-936.
A critical component of strong safety culture is that patients and families feel empowered to speak up about safety concerns. Patients and families are often the first to notice changes in their well-being and consistently identify unique adverse events that are not detected through provider-driven means. This cross-sectional survey asked patients currently hospitalized in an intensive care unit (ICU) and their families about their comfort discussing safety concerns with their health care team, then validated those responses with an Internet-recruited nationwide cohort of patients and families who had been previously cared for in ICUs. Many current ICU patients and families expressed some reticence to speak up. Common reasons cited were concern that the health care team was too busy, fear of being labeled a troublemaker, and worry that the team would judge them for not understanding the medical details of their care.
Sinow CS, Corso I, Lorenzo J, et al. Crit Care Med. 2017;45:1915-1921.
Patients with limited English proficiency may be at higher risk for adverse events, including medication errors. Use of professional medical interpreters has been shown to improve the quality of care provided to patients with limited English proficiency. In this observational study at a single children's hospital, researchers analyzed the transcripts of nine family meetings and found that Spanish medical interpreters frequently altered the original speech of providers and family members. The authors suggest that when using medical interpreters, providers should pause frequently, allowing for translation of shorter statements to improve accuracy of translation.
Lyndon A, Wisner K, Holschuh C, et al. J Obstet Gynecol Neonatal Nurs. 2017;46:716-726.
Parents and families are crucial partners in pediatric patient safety. This qualitative study of parents whose infants were hospitalized in the neonatal intensive care unit developed a conceptual model for how and when parents articulate safety concerns.
Tothy AS, Limper HM, Driscoll J, et al. Jt Comm J Qual Patient Saf. 2016;42:281-5.
This study reports on efforts to enhance communication between clinicians and patients in an urban pediatric emergency department. A rapid-change project resulted in significant improvement in patient perceptions of communication—clinicians were perceived as being more sensitive to patients' concerns and displayed better listening behaviors. Poor discharge communication in the emergency department has been linked to safety concerns in prior studies.
Stickney CA, Ziniel SI, Brett MS, et al. J Pediatr. 2014;165:1245-1251.e1.
In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.
Lyndon A, Jacobson CH, Fagan KM, et al. BMJ Qual Saf. 2014;23:902-9.
This interview, observation, and survey study found that parents of infants in neonatal intensive care units identified three core aspects of safety: physical safety relating to immediate treatment, the effect of care on future development, and emotional safety for infants and family, such as having confidence in caregivers. These results argue for enhancing patient and family engagement in safety in this setting.
Corbally MT, Tierney E. Int J Pediatr. 2014;2014:791490.
Many institutions are attempting to increase patient and family engagement in safety efforts. This report on integrating parents of children undergoing surgery into the completion of the WHO surgical safety checklist provides a helpful example of families being successfully incorporated into an existing safety program.
Dodek PM, Wong H, Heyland DK, et al. Crit Care Med. 2012;40:1506-12.
A positive safety culture has been linked to improved staff satisfaction as well as a lower incidence of errors. This study, conducted in 23 Canadian intensive care units (ICUs), sought to examine the relationship between safety culture and families' satisfaction with care. The authors found a strong positive correlation between safety culture and family satisfaction with care among a subset of patients who had prolonged and ultimately fatal ICU stays. This finding implies that families of patients who have lengthy hospitalizations are affected by the safety and organizational culture of the units where their loved ones are being cared for and that improving safety culture may also improve patient and family satisfaction with care.
Hueckel RM, Mericle JM, Frush K, et al. J Nurs Care Qual. 2012;27:176-81.
Some hospitals have begun allowing patients and families to directly summon a rapid response team. This implementation study reports on the training process for establishing a family-activated rapid response team at a children's hospital.
The central tenet behind rapid response systems (RRS) is that any provider should be able to summon prompt assistance if concerned about a patient. In the spirit of the National Patient Safety Goal that calls for engaging patients in safety efforts, some hospitals are now allowing patients and families to call the rapid response team directly. This report from a community hospital discusses the education and implementation process and describes the first series of RRS calls initiated by family members. Many of the family-initiated calls revealed communication issues between patients and clinicians, which the RRS was able to successfully negotiate.
Doucette E, Fazio S, LaSalle V, et al. Dynamics. 2010;21:16-9.
This article reports how nurses followed Canadian Disclosure Guidelines in disclosing sentinel events to patients and families and describes the benefits of using such guidelines for these discussions.
Daniels JP, King AD, Cochrane D, et al. Int J Med Inform. 2010;79:339-48.
This study describes the development and validation of a web-based tool that allows families to report adverse events during pediatric hospitalizations. The most frequent reports filed were around miscommunication between staff.
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