Identification by families of pediatric adverse events and near misses overlooked by health care providers

Daniels, Jeremy; Hunc, Kate; Cochrane, D. Douglas; Carr, Roxane; Shaw, Nicola; Taylor, A. E.; Heathcote, Susan; Brant, Rollin; Lim, Joanne; Ansermino, J. Mark

doi:10.1503/cmaj.110393

Cited by 57 publications

(68 citation statements)

References 15 publications

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“…36 Prior studies using active patient and family reporting similarly found that 23% to 49% of patients and families reported safety concerns. 16,17,19 These studies used various methods, including post discharge patient telephone interviews, 16 computer-based safety-reporting parent discharge surveys, 17 and in-person patient/caregiver interviews 2 to 3 times per week. 19 An important difference between our study and these is that we subsequently validated family safety reporting using a rigorous 2-step methodology.…”

Section: Discussionmentioning

confidence: 99%

Families as Partners in Hospital Error and Adverse Event Surveillance

Khan¹,

Coffey²,

Litterer³

et al. 2017

JAMA Pediatr

116

115

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Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. OBJECTIVE To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. DESIGN, SETTING, AND PARTICIPANTSWe conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. MAIN OUTCOMES AND MEASURES Error and AE rates.RESULTS Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P=.006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.CONCLUSIONS AND RELEVANCE Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better des...

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Section: Discussionmentioning

confidence: 99%

Families as Partners in Hospital Error and Adverse Event Surveillance

Khan¹,

Coffey²,

Litterer³

et al. 2017

JAMA Pediatr

116

115

View full text Add to dashboard Cite

show abstract

Section: Discussionmentioning

confidence: 99%

“…17 A few adult studies have found that patients identify numerous verified errors and AEs not otherwise documented in the medical record. [18][19][20] Pediatric data on patient and family involvement in error and AE detection are limited [21][22][23][24] but similarly suggest that families often report verified errors and AEs that are not detected through other sources. 23 Given the family's central role in pediatrics, parent-reported errors may be a fruitful source of error and AE surveillance for hospitalized children and may provide lessons regarding the utility of family error reporting in other populations.…”

Section: Main Outcomes and Measures-medical Errors And Preventable Aesmentioning

confidence: 99%

“…19,20 Our error and preventable AE rates were lower than patient-reported AE rates found in 2 adult studies, which detected AEs in 23% of patients 18 and 8.8 per 100 admissions, 20 respectively, and are likewise lower than a Canadian pediatric study that found 28.1 errors and AEs per 100 admissions. 23 It is unclear whether differences in reported rates are due to differences in data collection methods, patient populations, or true differences in AE and error rates across institutions.When examining predictors of parent-reported errors, length of stay and the presence of certain CCCs were associated with higher rates of error. Longer length of stay has previously been found to be associated with an increased likelihood of experiencing a medical error, 28 likely owing to both increased exposure to the risk of an error and because patients who experience AEs may consequently have prolonged lengths of stay.…”

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confidence: 99%

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Parent-Reported Errors and Adverse Events in Hospitalized Children

et al. 2016

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“…Yet the one source of experience and expertise that remains largely ignored is that of the patient. 1 In their study in this issue of CMAJ of reporting of adverse events, Daniels and colleagues 2 show that parents of children undergoing care in hospital can provide timely and important information about the safety of care that complements information recorded in staff reporting systems. Information from fam ilies revealed many harmful and potentially harmful events that would have otherwise remained undetected.…”

mentioning

confidence: 99%