Email Updates
Certain groups of people disproportionately experience avoidable harm in our healthcare system. Over the course of 2023, research posted to AHRQ PSNet has focused on the issue of equity in patient safety. This Year in Review Perspective discusses this body of research, through findings on clinician bias, technological tools, current initiatives directed at improving health equity, and in clinical areas such as obstetrics.
Throughout 2023, the importance of communication during transitions of care was a recurrent theme among articles on AHRQ PSNet. This Year in Review Perspective for 2023 discusses strategies for effective communication during transitions of care, spanning interactions among healthcare professionals, across organizations, and with patients, families, and caregivers.
Throughout 2023, the importance patient safety culture and workforce safety culture were recurrent themes among articles on AHRQ PSNet. This Year in Review Perspective for 2023 discusses concepts of psychological safety and employee voice, individual and team factors, and leadership and organizational factors related to safety culture.
This piece discusses the threat that cybersecurity attacks pose to patient safety, as well as ways to prepare and respond to attacks.
John Riggi is the national advisor for cybersecurity and risk at the American Hospital Association. Barbara Pelletreau is a former senior vice president of patient safety for a large healthcare organization. We spoke to them about the risks of cybersecurity to patient safety and how organizations can prepare and respond to cyberattacks.
Monika Haugstetter, MHA, MSN, RN, CPHQ, is a Health Science Administrator with AHRQ, leading AHRQ’s TeamSTEPPS® initiative. Stephen Hines, PhD, is a Senior Research Scientist at the Arbor Research Collaborative for Health. While at Abt Associates, he co-led the TeamSTEPPS 3.0 revisions in collaboration with AHRQ. We spoke with Monika and Stephen about the newly released TeamSTEPPS 3.0 curriculum.
This piece discusses the impact of AHRQ’s TeamSTEPPS training curriculum on patient safety and highlights updates made to the curriculum in 2023 with the launch of TeamSTEPPS 3.0.
This perspective discusses patient safety in office-based care settings, where most patients get their healthcare. We discuss patient safety events that arise in routine office-based settings and those more particular to procedures performed in office-based ambulatory surgery centers. Communication strategies can mitigate safety risks and can be applied in many healthcare settings.
Richard Ricciardi is the associate dean for clinical practice and community engagement and the executive director of the Center for Health Policy and Media Engagement at the George Washington University. He has served as the director of the Division of Practice Improvement and senior advisor for nursing at AHRQ, and he maintains a part-time clinical practice at Mercy Health Clinic. We spoke to him on patient safety in office-based settings.
Summary
Medical errors (all errors in medicine), harmful errors (medical errors that specifically lead to patient harm), and adverse events (harms due to medical care) are leading causes of death and harm in patients in the hospital setting.1,2 Communication failures are a common root cause of sentinel events, which are the most serious harmful errors.3 Minimal research has investigated whether efforts to reduce communication failures across healthcare providers, patients, and families could improve patient safety.4 This intervention sought to determine whether patient safety and communication processes could be improved via a family-centered communication program. Harvard Medical School and Boston Children’s Hospital designed a prospective, multicenter before-and-after intervention study in which families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds in hospitals. This approach is also known as family-centered rounds.4
The intervention was conducted on seven pediatric units across the United States and Canada from December 2014 to January 2017. Before the intervention, most sites did not have a formal structure for rounds.4 This intervention, known as Patient and Family Centered I-PASS, was based off of the I-PASS Resident Handoff Study.5 It was adapted for the current study. A team of parents and healthcare professionals adapted the I-PASS framework5 to provide a formal structure for family-centered rounds. I-PASS stands for Illness severity (family reports if child was better, worse, or the same), Patient summary (brief summary of patient presentation, overnight events, plan), Action list (to-dos for the day), Situation awareness and contingency planning (what family and staff should look out for and what might happen), and Synthesis by receiver (family reads back key points of plan for the day, prompted by presenter and supported by nurse as needed).4 In addition to structuring communication on rounds around the I-PASS framework, the intervention sought to engage families in rounds by having them share their questions and concerns first and ensuring providers used simple language instead of medical jargon. The intervention engaged nurses to be present and speak early on rounds and support families. Finally, it involved a written summary of rounds filled out in real time, known as the Rounds Report.
The study team reviewed 3,106 patient admissions (1,574 preintervention and 1,532 postintervention), or a total of 13,171 patient days (6,326 preintervention and 6,845 postintervention) for medical errors, harmful errors, and nonpreventable adverse events.4 After the standardized family-centered rounds intervention was implemented, harmful errors decreased by 38% (20.7 per 1,000 patient days preintervention to 12.9 per 1,000 days postintervention; p=0.01).4 The overall rate of medical errors and nonharmful medical errors did not change.4
The study also had an unexpected decrease in nonpreventable adverse events. They decreased from 12.6 per 1,000 preintervention to 5.2 per 1,000 postintervention (p=0.003).4 This unexpected improvement may be due to improved engagement and communication with families, which prevented some adverse events from occurring in ways not apparent in the normal determination of adverse events.4 The reduction in harmful events occurred without significantly increasing the duration of rounds.4 Additionally, the intervention was found to improve key communication behaviors, like family and nurse engagement on rounds, and several measures of family experience.4
Per the innovator, Patient and Family Centered I-PASS is a novel approach in the patient safety movement. This innovation can be applied in many other settings of care, such as nursing homes and rehabilitation centers. Patient and Family Centered I-PASS has the potential to significantly reduce medical errors.
Innovation Patient Safety Focus
The Patient and Family Centered I-PASS innovation aimed to improve patient safety by improving health literacy, family engagement, and bidirectional structured communication between healthcare providers and patients’ families through the use of the modified I-PASS framework to standardize family-centered rounds.4
Evidence Rating
Resources Used and Skills Needed
- Institutional support: Leadership support for the intervention
- Buy-in from families and the patient’s team of healthcare providers
- Unit physician and nursing champions who can help support implementation and training
- Support from families in sustaining the innovation
- Time and finances to properly train families and the patient’s healthcare team on the intervention. This includes a family orientation via brochures (for families, training on the content in the brochures is conducted by nurse staff), training modules (for healthcare providers), and the review of an implementation guide (for healthcare providers).4
- The implementation of observational tools (including core items and modules on activating and engaging the family and interprofessional team, patient-centered conversation and written information, use of structured communication techniques, and teaching) to ensure intervention adherence and improvement through audit and feedback4
- Disseminate campaign materials to encourage adoption of the intervention4
- Conduct meetings and teleconferences across sites, if the intervention is implemented across multiple sites, to track innovation progress and to address any challenges discovered during implementation4
- Conduct statistical analyses to assess changes in patient safety (medical errors and adverse events) and communication processes4
- Interpretation and translation resources for those who speak languages other than English
Use By Other Organizations
Per the innovator, engaging families in rounds has traditionally been done in the pediatric setting. Understanding where family-centered rounds could fit into the adult care setting has the potential to make a major impact. This innovation has the potential to improve health equity by ensuring standardized, clear communication and a partnership with patients and families.
