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.

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

• 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

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.

During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.¹

The I-READI acronym outlines the steps (i.e., Integration, Root-Cause Analysis, Evidence Review, Adaptation, Dissemination, and Implementation) the team took in response to a higher-than-expected rate of endotracheal tube obstruction and reintubation among patients with COVID-19. The first step and the foundation of the I-READI framework is the integration of quality and safety bodies into vertical and horizontal communication pathways. The structures for this essential step should be in place before a crisis. For example, the innovation team reacted quickly by leveraging existing structures to expand and streamline communication channels, including through daily COVID-19 safety huddles that directly connected frontline providers with the health system’s multidisciplinary Critical Care Committee leaders. After they were aware of the problem, team members conducted an aggregate root-cause analysis on the airway complications. They also reviewed available emerging evidence, which was at times anecdotal and evolving day to day, by consulting with colleagues and experts. After gathering information, considering occasionally disparate opinions, and drawing on multidisciplinary expertise, the team adapted their protocols for treating ventilated patients, including changing the risk categorization of patients with COVID-19, issuing stricter guidelines for monitoring for airway resistance, and increasing ventilator humidification. Just over a week after the identification of the first safety incidents, the team disseminated the revised protocols using strengthened and expanded communications channels such as daily and ad hoc huddles, web-based teaching modules, standing conferences, and user-friendly one-page clinical guides. To support implementation, unit leaders provided just-in-time training, ICU dashboards facilitated a rapid scale-up of new patient safety checklist components, and offsite respiratory therapists oversaw revised ventilation procedures via remote video monitoring.

Within two weeks from the time that pulmonary and critical care clinicians sounded an alarm about the airway complications, rates of endotracheal tube obstruction and reintubation declined to pre-COVID-19 levels. The team attributed their success in quickly addressing the problem to the health system’s ability to rapidly strengthen safety communications pathways, in addition to the hard work, multidisciplinary teamwork, and dedication of all those who contributed.

The I-READI framework innovation provides a step-by-step guide for healthcare systems to prepare for and respond to healthcare safety events in unpredictable conditions. Specifically, the framework applies to situations in which clinical protocols must be quickly evaluated, revised, and disseminated.

To implement the I-READI framework, healthcare systems require established multidisciplinary safety and quality teams that allow for vertical communication (i.e., from frontline workers to unit leaders and hospital administrators) and horizontal communication (i.e., bridging specialties and facilities across a healthcare system). The innovation team stressed the importance of having communications and reporting platforms in place such as real time patient monitoring dashboards and safety huddles.

The innovation also requires that team members have skills and experience with aggregate root-cause analysis to review multiple cases of common adverse events. Team members should be able to assess how other sites are approaching similar issues by accessing their external peer networks. Technical resources such as real-time data monitoring capabilities and conducting remote tele-consults are also helpful. However, the innovation team emphasizes that material resources are less important than the ability of staff to come together for a common cause, communicate directly and efficiently across hierarchy and discipline, and commit their time to finding solutions.

The innovation team published an article on the innovation in the New England Journal of Medicine in January 2021 and has since received several inquiries from interested organizations.