PMID- 28241211
OWN - NLM
STAT- MEDLINE
DCOM- 20170705
LR  - 20240326
IS  - 2168-6211 (Electronic)
IS  - 2168-6203 (Print)
IS  - 2168-6203 (Linking)
VI  - 171
IP  - 4
DP  - 2017 Apr 1
TI  - Families as Partners in Hospital Error and Adverse Event Surveillance.
PG  - 372-381
LID - 10.1001/jamapediatrics.2016.4812 [doi]
AB  - 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%; kappa, 
      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.
FAU - Khan, Alisa
AU  - Khan A
AD  - Division of General Pediatrics, Department of Medicine, Boston Children's 
      Hospital, Boston, Massachusetts.
AD  - Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
FAU - Coffey, Maitreya
AU  - Coffey M
AD  - Centre for Quality Improvement and Patient Safety, Department of Paediatrics, 
      Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
FAU - Litterer, Katherine P
AU  - Litterer KP
AD  - Center for Families, Boston Children's Hospital, Boston, Massachusetts.
FAU - Baird, Jennifer D
AU  - Baird JD
AD  - Department of Nursing, Cardiovascular, and Critical Care Services, Boston 
      Children's Hospital, Boston, Massachusetts.
FAU - Furtak, Stephannie L
AU  - Furtak SL
AD  - Division of General Pediatrics, Department of Medicine, Boston Children's 
      Hospital, Boston, Massachusetts.
FAU - Garcia, Briana M
AU  - Garcia BM
AD  - Division of General Pediatrics, Department of Medicine, Boston Children's 
      Hospital, Boston, Massachusetts.
FAU - Ashland, Michele A
AU  - Ashland MA
AD  - Family-Centered Care, Lucile Packard Children's Hospital, Palo Alto, California.
FAU - Calaman, Sharon
AU  - Calaman S
AD  - Section of Critical Care, Department of Pediatrics, St Christopher's Hospital for 
      Children, Drexel University College of Medicine, Philadelphia, Pennsylvania.
FAU - Kuzma, Nicholas C
AU  - Kuzma NC
AD  - Section of Hospital Medicine, Department of Pediatrics, St Christopher's Hospital 
      for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania.
FAU - O'Toole, Jennifer K
AU  - O'Toole JK
AD  - Department of Pediatrics, Cincinnati Children's Hospital, University of 
      Cincinnati College of Medicine, Cincinnati, Ohio.
FAU - Patel, Aarti
AU  - Patel A
AD  - Department of Pediatrics, Cincinnati Children's Hospital, University of 
      Cincinnati College of Medicine, Cincinnati, Ohio.
FAU - Rosenbluth, Glenn
AU  - Rosenbluth G
AD  - Department of Pediatrics, Benioff Children's Hospital, University of 
      California-San Francisco School of Medicine, San Francisco.
FAU - Destino, Lauren A
AU  - Destino LA
AD  - Division of Pediatric Hospital Medicine, Lucile Packard Children's Hospital, 
      Stanford University School of Medicine, Palo Alto, California.
FAU - Everhart, Jennifer L
AU  - Everhart JL
AD  - Division of Pediatric Hospital Medicine, Lucile Packard Children's Hospital, 
      Stanford University School of Medicine, Palo Alto, California.
FAU - Good, Brian P
AU  - Good BP
AD  - Department of Pediatrics, Primary Children's Hospital, University of Utah School 
      of Medicine, Salt Lake City.
FAU - Hepps, Jennifer H
AU  - Hepps JH
AD  - Department of Pediatrics, Walter Reed National Military Medical Center, Uniformed 
      Services University of the Health Sciences, Bethesda, Maryland.
FAU - Dalal, Anuj K
AU  - Dalal AK
AD  - Department of Medicine, Harvard Medical School, Boston, Massachusetts.
AD  - The Center for Patient Safety Research and Practice, Division of General 
      Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
FAU - Lipsitz, Stuart R
AU  - Lipsitz SR
AD  - Department of Medicine, Harvard Medical School, Boston, Massachusetts.
AD  - The Center for Patient Safety Research and Practice, Division of General 
      Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
FAU - Yoon, Catherine S
AU  - Yoon CS
AD  - The Center for Patient Safety Research and Practice, Division of General 
      Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
FAU - Zigmont, Katherine R
AU  - Zigmont KR
AD  - The Center for Patient Safety Research and Practice, Division of General 
      Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
FAU - Srivastava, Rajendu
AU  - Srivastava R
AD  - Department of Pediatrics, Primary Children's Hospital, University of Utah School 
      of Medicine, Salt Lake City.
AD  - Institute for Healthcare Delivery Research, Intermountain Healthcare, Salt Lake 
      City, Utah.
FAU - Starmer, Amy J
AU  - Starmer AJ
AD  - Division of General Pediatrics, Department of Medicine, Boston Children's 
      Hospital, Boston, Massachusetts.
AD  - Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
FAU - Sectish, Theodore C
AU  - Sectish TC
AD  - Division of General Pediatrics, Department of Medicine, Boston Children's 
      Hospital, Boston, Massachusetts.
AD  - Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
FAU - Spector, Nancy D
AU  - Spector ND
AD  - Section of General Pediatrics, Department of Pediatrics, St Christopher's 
      Hospital for Children, Drexel University College of Medicine, Philadelphia, 
      Pennsylvania.
FAU - West, Daniel C
AU  - West DC
AD  - Department of Pediatrics, Benioff Children's Hospital, University of 
      California-San Francisco School of Medicine, San Francisco.
FAU - Landrigan, Christopher P
AU  - Landrigan CP
AD  - Division of General Pediatrics, Department of Medicine, Boston Children's 
      Hospital, Boston, Massachusetts.
AD  - Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
AD  - Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, 
      Boston, Massachusetts.
CN  - the Patient and Family Centered I-PASS Study Group
FAU - Allair, Brenda K
AU  - Allair BK
AD  - Boston Children's Hospital, Boston, Massachusetts.
FAU - Alminde, Claire
AU  - Alminde C
AD  - St Christopher's Hospital for Children, Philadelphia, Pennsylvania.
FAU - Alvarado-Little, Wilma
AU  - Alvarado-Little W
AD  - Alvarado-Little Consulting LLC, Albany, New York.
FAU - Atsatt, Marisa
AU  - Atsatt M
AD  - Lucile Packard Children's Hospital, Stanford, California.
FAU - Aylor, Megan E
AU  - Aylor ME
AD  - Doernbecher Children's Hospital, Oregon Health and Science University, Portland.
FAU - Bale, James F Jr
AU  - Bale JF Jr
AD  - Primary Children's Hospital, Intermountain Healthcare, University of Utah School 
      of Medicine, Salt Lake City.
FAU - Balmer, Dorene
AU  - Balmer D
AD  - Children's Hospital of Philadelphia, University of Pennsylvania Perelman School 
      of Medicine, Philadelphia.
FAU - Barton, Kevin T
AU  - Barton KT
AD  - St Louis Children's Hospital, Washington University School of Medicine, St Louis, 
      Missouri.
FAU - Beck, Carolyn
AU  - Beck C
AD  - Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
FAU - Bismilla, Zia
AU  - Bismilla Z
AD  - Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
FAU - Blankenburg, Rebecca L
AU  - Blankenburg RL
AD  - Lucile Packard Children's Hospital, Stanford University, Stanford, California.
FAU - Chandler, Debra
AU  - Chandler D
AD  - Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
FAU - Choudhary, Amanda
AU  - Choudhary A
AD  - Primary Children's Hospital, Salt Lake City, Utah.
FAU - Christensen, Eileen
AU  - Christensen E
AD  - Primary Children's Hospital, Salt Lake City, Utah.
FAU - Coghlan-McDonald, Sally
AU  - Coghlan-McDonald S
AD  - Benioff Children's Hospital, San Francisco, California.
FAU - Cole, F Sessions
AU  - Cole FS
AD  - St Louis Children's Hospital, Washington University School of Medicine, St Louis, 
      Missouri.
FAU - Corless, Elizabeth
AU  - Corless E
AD  - Primary Children's Hospital, Salt Lake City, Utah.
FAU - Cray, Sharon
AU  - Cray S
AD  - St Christopher's Hospital for Children, Philadelphia, Pennsylvania.
FAU - Da Silva, Roxi
AU  - Da Silva R
AD  - Walter Reed National Military Medical Center, Bethesda, Maryland.
FAU - Dahale, Devesh
AU  - Dahale D
AD  - Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
FAU - Dreyer, Benard
AU  - Dreyer B
AD  - New York University Langone Medical Center, New York University School of 
      Medicine, New York.
FAU - Growdon, Amanda S
AU  - Growdon AS
AD  - Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
FAU - Gubler, LeAnn
AU  - Gubler L
AD  - Primary Children's Hospital, Salt Lake City, Utah.
FAU - Guiot, Amy
AU  - Guiot A
AD  - Cincinnati Children's Hospital Medical Center, University of Cincinnati College 
      of Medicine, Cincinnati, Ohio.
FAU - Harris, Roben
AU  - Harris R
AD  - St Louis Children's Hospital, St Louis, Missouri.
FAU - Haskell, Helen
AU  - Haskell H
AD  - Mothers Against Medical Error, Columbia, South Carolina.
FAU - Kocolas, Irene
AU  - Kocolas I
AD  - Primary Children's Hospital, Intermountain Healthcare, University of Utah School 
      of Medicine, Salt Lake City.
FAU - Kruvand, Elizabeth
AU  - Kruvand E
AD  - St Louis Children's Hospital, St Louis, Missouri.
FAU - Lane, Michele Marie
AU  - Lane MM
AD  - St Louis Children's Hospital, St Louis, Missouri.
FAU - Langrish, Kathleen
AU  - Langrish K
AD  - Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
FAU - Ledford, Christy J W
AU  - Ledford CJW
AD  - Walter Reed National Military Medical Center, Uniformed Services University of 
      the Health Sciences, Bethesda, Maryland.
FAU - Lewis, Kheyandra
AU  - Lewis K
AD  - St Christopher's Hospital for Children, Drexel University College of Medicine, 
      Philadelphia, Pennsylvania.
FAU - Lopreiato, Joseph O
AU  - Lopreiato JO
AD  - Walter Reed National Military Medical Center, Uniformed Services University of 
      the Health Sciences, Bethesda, Maryland.
FAU - Maloney, Christopher G
AU  - Maloney CG
AD  - Primary Children's Hospital, Intermountain Healthcare, University of Utah School 
      of Medicine, Salt Lake City.
FAU - Mangan, Amanda
AU  - Mangan A
AD  - Benioff Children's Hospital, San Francisco, California.
FAU - Markle, Peggy
AU  - Markle P
AD  - Walter Reed National Military Medical Center, Bethesda, Maryland.
FAU - Mendoza, Fernando
AU  - Mendoza F
AD  - Lucile Packard Children's Hospital, Stanford University, Stanford, California.
FAU - Micalizzi, Dale Ann
AU  - Micalizzi DA
AD  - Justin's HOPE Project, Task Force for Global Health, Decatur, Georgia.
FAU - Mittal, Vineeta
AU  - Mittal V
AD  - Children's Medical Center Dallas, University of Texas Southwestern Medical 
      Center, Dallas.
FAU - Obermeyer, Maria
AU  - Obermeyer M
AD  - Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
FAU - O'Donnell, Katherine A
AU  - O'Donnell KA
AD  - Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
FAU - Ottolini, Mary
AU  - Ottolini M
AD  - Children's National Health System, George Washington University School of 
      Medicine, Washington, DC.
FAU - Patel, Shilpa J
AU  - Patel SJ
AD  - Kapi'olani Medical Center for Women and Children, University of Hawai'i John A. 
      Burns School of Medicine, Honolulu.
FAU - Pickler, Rita
AU  - Pickler R
AD  - Ohio State University, Columbus.
FAU - Rogers, Jayne Elizabeth
AU  - Rogers JE
AD  - Boston Children's Hospital, Boston, Massachusetts.
FAU - Sanders, Lee M
AU  - Sanders LM
AD  - Lucile Packard Children's Hospital, Stanford University, Stanford, California.
FAU - Sauder, Kimberly
AU  - Sauder K
AD  - St Louis Children's Hospital, St Louis, Missouri.
FAU - Shah, Samir S
AU  - Shah SS
AD  - Cincinnati Children's Hospital Medical Center, University of Cincinnati College 
      of Medicine, Cincinnati, Ohio.
FAU - Sharma, Meesha
AU  - Sharma M
AD  - Boston Children's Hospital, Boston, Massachusetts.
FAU - Simpkin, Arabella
AU  - Simpkin A
AD  - Harvard Medical School, Boston, Massachusetts.
FAU - Subramony, Anupama
AU  - Subramony A
AD  - Cohen Children's Medical Center, Hofstra Northwell School of Medicine, East 
      Garden City, New York.
FAU - Thompson, E Douglas Jr
AU  - Thompson ED Jr
AD  - St Christopher's Hospital for Children, Drexel University College of Medicine, 
      Philadelphia, Pennsylvania.
FAU - Trueman, Laura
AU  - Trueman L
AD  - Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
FAU - Trujillo, Tanner
AU  - Trujillo T
AD  - Primary Children's Hospital, Salt Lake City, Utah.
FAU - Turmelle, Michael P
AU  - Turmelle MP
AD  - St Louis Children's Hospital, Washington University School of Medicine, St Louis, 
      Missouri.
FAU - Warnick, Cindy
AU  - Warnick C
AD  - Primary Children's Hospital, Salt Lake City, Utah.
FAU - Welch, Chelsea
AU  - Welch C
AD  - Primary Children's Hospital, Salt Lake City, Utah.
FAU - White, Andrew J
AU  - White AJ
AD  - St Louis Children's Hospital, Washington University School of Medicine, St Louis, 
      Missouri.
FAU - Wien, Matthew F
AU  - Wien MF
AD  - Brigham and Women's Hospital, Boston, Massachusetts.
FAU - Winn, Ariel S
AU  - Winn AS
AD  - Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
FAU - Wintch, Stephanie
AU  - Wintch S
AD  - Lucile Packard Children's Hospital, Stanford, California.
FAU - Wolf, Michael
AU  - Wolf M
AD  - Northwestern University Feinberg School of Medicine, Evanston, Illinois.
FAU - Yin, H Shonna
AU  - Yin HS
AD  - New York University Langone Medical Center, New York University School of 
      Medicine, New York.
FAU - Yu, Clifton E
AU  - Yu CE
AD  - Walter Reed National Military Medical Center, Uniformed Services University of 
      the Health Sciences, Bethesda, Maryland.
LA  - eng
GR  - K12 HS022986/HS/AHRQ HHS/United States
GR  - T32 HS000063/HS/AHRQ HHS/United States
PT  - Journal Article
PT  - Research Support, U.S. Gov't, P.H.S.
PL  - United States
TA  - JAMA Pediatr
JT  - JAMA pediatrics
JID - 101589544
SB  - IM
EIN - JAMA Pediatr. 2018 Mar 1;172(3):302. PMID: 29309482
MH  - Adult
MH  - Child
MH  - Child, Hospitalized/*statistics & numerical data
MH  - Cohort Studies
MH  - Family
MH  - Female
MH  - Hospitals, Pediatric/*statistics & numerical data
MH  - Humans
MH  - Male
MH  - Medical Errors/*statistics & numerical data
MH  - Prospective Studies
MH  - United States
PMC - PMC5526631
MID - NIHMS870784
COIS- Conflict of Interest Disclosures: Drs Landrigan, Sectish, Spector, Srivastava, 
      Starmer, and West have consulted with and hold equity in the I-PASS Institute, 
      which seeks to train institutions in best handoff practices and aid in their 
      implementation. Drs Sectish, Spector, Srivastava, Starmer, and West have received 
      monetary awards, honoraria, and travel reimbursement from multiple academic and 
      professional organizations for teaching and consulting on physician performance 
      and handoffs. Drs Landrigan and Srivastava are supported in part by the 
      Children's Hospital Association for their work as Executive Council members of 
      the Pediatric Research in Inpatient Settings (PRIS) network. Dr Landrigan has 
      also served as a paid consultant to Virgin Pulse to help develop a Sleep and 
      Health Program. In addition, Dr Landrigan has received monetary awards, 
      honoraria, and travel reimbursement from multiple academic and professional 
      organizations for teaching and consulting on sleep deprivation, physician 
      performance, handoffs, and safety and has served as an expert witness in cases 
      regarding patient safety and sleep deprivation. No other disclosures were 
      reported.
EDAT- 2017/02/28 06:00
MHDA- 2017/07/06 06:00
PMCR- 2018/04/01
CRDT- 2017/02/28 06:00
PHST- 2017/02/28 06:00 [pubmed]
PHST- 2017/07/06 06:00 [medline]
PHST- 2017/02/28 06:00 [entrez]
PHST- 2018/04/01 00:00 [pmc-release]
AID - 2604750 [pii]
AID - 10.1001/jamapediatrics.2016.4812 [doi]
PST - ppublish
SO  - JAMA Pediatr. 2017 Apr 1;171(4):372-381. doi: 10.1001/jamapediatrics.2016.4812.