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What was the research about?

Even with ongoing efforts to improve care, medical errors still happen in hospitals. Medical errors are mistakes that may or may not cause harm to patients. An example of a medical error is when a doctor prescribes the wrong medicine to a patient. When medical care causes harm, it is known as an adverse event, for example when a patient has an allergic reaction to a prescribed medicine.

In this study, the research team wanted to see if improving communication would help reduce hospital medical errors and adverse events. The team created a program to help doctors and nurses communicate with families during rounds. Rounds are meetings every day when hospital staff, usually doctors and nurses, review patients’ progress. Then staff come up with a plan for the day. Staff often make these plans without direct input from the patient or their family.

The program took place in hospital pediatric units, where children receive care. The program included

• A way to make sure that doctors and nurses included families on daily rounds
• A way to make sure medical staff talked about everything important on daily rounds
• Write-ups of rounds for patients and their families
• Training to help staff learn how to include families in the rounds

What were the results?

Compared with before hospitals used the program, after hospitals used the program,

• There was no difference in overall medical errors, but patients had 38% fewer harmful medical errors.
• Patients had 46% fewer adverse events.
• Parents rated their child’s care experiences higher on 6 of 25 measures. None of the measures received a worse rating.
• Nurses and parents were more involved in rounds. For example, parents spoke up more and asked more questions.

Who was in the study?

The study included 3,106 children receiving care in pediatric units at seven hospitals in the United States and Canada. Of these, 51 percent were girls, and 8 percent had two or more long-term health problems. The average child’s age was seven years. The study also included 1,837 parents of children in the study. In addition, 925 doctors and nurses treating the children took part in the study.

What did the research team do?

The research team taught staff how to use the program for nine months. For three months before the training started and three months after the training ended, the team observed doctors, nurses, and parents to rate their communication. The team also looked for changes in medical errors and adverse events using hospital data, surveys of doctors and nurses, and reports from parents.

Family advisors, nurses, doctors, researchers, teachers, and people trained in health literacy helped plan and carry out the study.

What were the limits of the study?

Because of the design of this study, it isn’t possible to know for sure if the changes in medical errors and adverse events happened because of the program or because of something else that occurred at the same time. This study focused on children and their parents. The program might not have the same results with hospitals that care for adults.

Future research could test the program with hospitals that care for adults as well as children.

How can people use the results?

Doctors and hospitals can use this program to improve how well doctors, nurses, and families communicate and to improve patient safety.

Objective

To test the effectiveness of a program to improve communication between physicians, nurses, and families and to better involve families in all aspects of daily decision making in hospital pediatric units

Study Design

This study tested the effectiveness of Patient and Family Centered I-PASS, a program that facilitates information exchange between physicians, nurses, patients, and families to reduce medical errors and adverse events. Medical errors are failures in the delivery of medical care. Adverse events are harms to patients due to medical care.

Patient and Family Centered I-PASS uses a structured communication program. It includes a framework to better engage patients and families by making rounds more family centered, a staff training program, written rounds summaries for families, and strategies to support teamwork and implementation of the program.

The program took place over nine months at seven pediatric hospitals in the United States and Canada. Researchers measured outcomes three months before and after implementation. Intensive chart review, provider event-reporting surveys, and family safety interviews provided data on medical errors and adverse events. Researchers conducted structured observations of rounds to document communication processes.

Researchers recruited two groups of patients, parents, and clinicians—one for each measurement period. The preintervention group included 1,574 patient admissions. Of these, 52% were white, 20% were black, and 5% were Asian. Also, 9% had two or more complex chronic conditions and 50% were female. The postintervention group included 1,532 patient admissions. Of these, 47% were white, 17% were black, and 5% were Asian. Also, 7% had two or more complex chronic conditions and 51% were female. The study also included 947 parents of children under age 18 in the preintervention group and 890 parents in the postintervention group.

Hospital staff, including 595 resident physicians and 330 nurses, also participated across the preintervention and postintervention periods of the study.

Family members, nurses, physicians, researchers, and health literacy professionals provided input on all aspects of the study, including the design, delivery, and assessment of the intervention, and the reporting of results.

Results

In the postintervention period compared with the preintervention period, researchers found 38% fewer harmful medical errors (p=0.01), as well as 46% fewer adverse events overall (p=0.002). There were also fewer nonpreventable adverse events (p=0.003). The team found no significant differences in the overall medical error rate, which includes both harmful and nonharmful errors.

Compared with families in the preintervention period, families in the postintervention period gave higher scores on 6 of 25 survey items for family-reported experience (p=0.03); scores did not worsen for any items. Researchers also found an increase in family engagement (p=0.04) and nurse engagement (p=0.03) in the postintervention period compared with the preintervention period.

Family-centered rounds occurred more frequently (p=0.02) in the postintervention period than in the preintervention period. Teaching of resident physicians during rounds and rounds duration did not differ between the two periods.

Limitations

Because this study did not use a randomized design, it is not possible to attribute changes in harmful medical errors and adverse events to the intervention with certainty.

Findings may not be generalizable to nonpediatric hospital units.

Conclusions and Relevance

After implementation of the program, patient safety, family engagement, and nurse engagement increased significantly compared with before the program, with no negative impact on teaching resident physicians and medical students during rounds or on rounds duration.

Future Research Needs

Future research could test how community and academic hospitals that care for adults as well as children can adapt Patient and Family Centered I-PASS for use across more diverse settings.