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Khan A, Coffey M, Litterer KP, Baird JD, Furtak SL, Garcia BM, Ashland MA, Calaman S, Kuzma NC, O'Toole JK, Patel A, Rosenbluth G, Destino LA, Everhart JL, Good BP, Hepps JH, Dalal AK, Lipsitz SR, Yoon CS, Zigmont KR, Srivastava R, Starmer AJ, Sectish TC, Spector ND, West DC, Landrigan CP, Allair BK, Alminde C, Alvarado-Little W, Atsatt M, Aylor ME, Bale JF, Balmer D, Barton KT, Beck C, Bismilla Z, Blankenburg RL, Chandler D, Choudhary A, Christensen E, Coghlan-McDonald S, Cole FS, Corless E, Cray S, Da Silva R, Dahale D, Dreyer B, Growdon AS, Gubler L, Guiot A, Harris R, Haskell H, Kocolas I, Kruvand E, Lane MM, Langrish K, Ledford CJW, Lewis K, Lopreiato JO, Maloney CG, Mangan A, Markle P, Mendoza F, Micalizzi DA, Mittal V, Obermeyer M, O'Donnell KA, Ottolini M, Patel SJ, Pickler R, Rogers JE, Sanders LM, Sauder K, Shah SS, Sharma M, Simpkin A, Subramony A, Thompson ED, Trueman L, Trujillo T, Turmelle MP, Warnick C, Welch C, White AJ, Wien MF, Winn AS, Wintch S, Wolf M, Yin HS, Yu CE. Families as Partners in Hospital Error and Adverse Event Surveillance. JAMA Pediatr 2017; 171:372-381. [PMID: 28241211 PMCID: PMC5526631 DOI: 10.1001/jamapediatrics.2016.4812] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Importance 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 Participants We 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 design and assessment of interventions to improve safety.
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Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Maitreya Coffey
- Centre for Quality Improvement and Patient Safety, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Jennifer D Baird
- Department of Nursing, Cardiovascular, and Critical Care Services, Boston Children's Hospital, Boston, Massachusetts
| | - Stephannie L Furtak
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Briana M Garcia
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michele A Ashland
- Family-Centered Care, Lucile Packard Children's Hospital, Palo Alto, California
| | - Sharon Calaman
- Section of Critical Care, Department of Pediatrics, St Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Nicholas C Kuzma
- Section of Hospital Medicine, Department of Pediatrics, St Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jennifer K O'Toole
- Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Aarti Patel
- Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn Rosenbluth
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco School of Medicine, San Francisco
| | - Lauren A Destino
- Division of Pediatric Hospital Medicine, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer L Everhart
- Division of Pediatric Hospital Medicine, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Brian P Good
- Department of Pediatrics, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City
| | - Jennifer H Hepps
- Department of Pediatrics, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Anuj K Dalal
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- The Center for Patient Safety Research and Practice, Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stuart R Lipsitz
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- The Center for Patient Safety Research and Practice, Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Catherine S Yoon
- The Center for Patient Safety Research and Practice, Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine R Zigmont
- The Center for Patient Safety Research and Practice, Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rajendu Srivastava
- Department of Pediatrics, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City
- Institute for Healthcare Delivery Research, Intermountain Healthcare, Salt Lake City, Utah
| | - Amy J Starmer
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Theodore C Sectish
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Nancy D Spector
- Section of General Pediatrics, Department of Pediatrics, St Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Daniel C West
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco School of Medicine, San Francisco
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Claire Alminde
- St Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | | | - Marisa Atsatt
- Lucile Packard Children's Hospital, Stanford, California
| | - Megan E Aylor
- Doernbecher Children's Hospital, Oregon Health and Science University, Portland
| | - James F Bale
- Primary Children's Hospital, Intermountain Healthcare, University of Utah School of Medicine, Salt Lake City
| | - Dorene Balmer
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Kevin T Barton
- St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Carolyn Beck
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Zia Bismilla
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Debra Chandler
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - F Sessions Cole
- St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
| | | | - Sharon Cray
- St Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Roxi Da Silva
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Devesh Dahale
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Benard Dreyer
- New York University Langone Medical Center, New York University School of Medicine, New York
| | - Amanda S Growdon
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - LeAnn Gubler
- Primary Children's Hospital, Salt Lake City, Utah
| | - Amy Guiot
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Roben Harris
- St Louis Children's Hospital, St Louis, Missouri
| | - Helen Haskell
- Mothers Against Medical Error, Columbia, South Carolina
| | - Irene Kocolas
- Primary Children's Hospital, Intermountain Healthcare, University of Utah School of Medicine, Salt Lake City
| | | | | | - Kathleen Langrish
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christy J W Ledford
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kheyandra Lewis
- St Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Joseph O Lopreiato
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Christopher G Maloney
- Primary Children's Hospital, Intermountain Healthcare, University of Utah School of Medicine, Salt Lake City
| | - Amanda Mangan
- Benioff Children's Hospital, San Francisco, California
| | - Peggy Markle
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Fernando Mendoza
- Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | | | - Vineeta Mittal
- Children's Medical Center Dallas, University of Texas Southwestern Medical Center, Dallas
| | - Maria Obermeyer
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Mary Ottolini
- Children's National Health System, George Washington University School of Medicine, Washington, DC
| | - Shilpa J Patel
- Kapi'olani Medical Center for Women and Children, University of Hawai'i John A. Burns School of Medicine, Honolulu
| | | | | | - Lee M Sanders
- Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | | | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | | - Anupama Subramony
- Cohen Children's Medical Center, Hofstra Northwell School of Medicine, East Garden City, New York
| | - E Douglas Thompson
- St Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Laura Trueman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Michael P Turmelle
- St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
| | | | | | - Andrew J White
- St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
| | | | - Ariel S Winn
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Michael Wolf
- Northwestern University Feinberg School of Medicine, Evanston, Illinois
| | - H Shonna Yin
- New York University Langone Medical Center, New York University School of Medicine, New York
| | - Clifton E Yu
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, Noble EL, Tse LL, Dalal AK, Keohane CA, Lipsitz SR, Rothschild JM, Wien MF, Yoon CS, Zigmont KR, Wilson KM, O'Toole JK, Solan LG, Aylor M, Bismilla Z, Coffey M, Mahant S, Blankenburg RL, Destino LA, Everhart JL, Patel SJ, Bale JF, Spackman JB, Stevenson AT, Calaman S, Cole FS, Balmer DF, Hepps JH, Lopreiato JO, Yu CE, Sectish TC, Landrigan CP. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014; 371:1803-12. [PMID: 25372088 DOI: 10.1056/nejmsa1405556] [Citation(s) in RCA: 553] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. METHODS We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. RESULTS In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. CONCLUSIONS Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).
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Affiliation(s)
- Amy J Starmer
- From the Department of Medicine, Division of General Pediatrics, Boston Children's Hospital (A.J.S., T.C.S., C.P.L., A.D.A., E.L.N., L.L.T.), Harvard Medical School (A.J.S., A.K.D., S.R.L., J.M.R., T.C.S., C.P.L.), Center for Patient Safety Research, Division of General Medicine (A.K.D., C.A.K., J.M.R., S.R.L., M.F.W., C.S.Y., K.R.Z.) and Division of Sleep Medicine (C.P.L.), Brigham and Women's Hospital, and CRICO/Risk Management Foundation (C.A.K.) - all in Boston; the Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health and Science University, Portland (A.J.S., M.A.); the Department of Pediatrics, Section of General Pediatrics (N.D.S.) and Section of Critical Care (S.C.), St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia; the Departments of Pediatrics (R.S., J.B.S., A.T.S.) and Neurology (J.F.B.), Primary Children's Hospital, Intermountain Healthcare, University of Utah School of Medicine, and Institute for Health Care Delivery Research, Intermountain Healthcare (R.S.), Salt Lake City; the Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco (D.C.W., G.R.), and the Department of Pediatrics, Division of General Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto (R.L.B., L.A.D., J.L.E., S.J.P.) - both in California; the Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (K.M.W.); the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati (J.K.O., L.G.S.); the Department of Paediatrics (Z.B., M.C., S.M.), Centre for Quality Improvement and Patient Safety (M.C.), and Institute for Health Policy, Management and Evaluation (S.M.), Hospital for Sick Children and University of Toronto, Toronto; the Department of Pediatrics, Division of General Pediatrics, Kapi'olani Medical Center for W
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