A Coproduced Family Reporting Intervention to Improve Safety Surveillance and Reduce Disparities.

OBJECTIVES: Examine family safety-reporting after implementing a parent-nurse-physician-leader coproduced, health literacy-informed, family safety-reporting intervention for hospitalized families of children with medical complexity. METHODS: We implemented an English and Spanish mobile family-safety-reporting tool, staff and family education, and process for sharing comments with unit leaders on a dedicated inpatient complex care service at a pediatric hospital. Families shared safety concerns via predischarge surveys (baseline and intervention) and mobile tool (intervention). Three physicians with patient safety expertise classified events. We compared safety-reporting baseline (via survey) versus intervention (via survey and/or mobile tool) with generalized estimating equations and sub-analyzed data by COVID-19-era and educational attainment. We also compared mobile tool-detected event rates with hospital voluntary incident reporting. RESULTS: 232 baseline and 208 intervention parents participated (78.2% consented); 29.5% of baseline families versus 38.2% of intervention families reported safety concerns (P = .09). Adjusted odds ratio (95% CI) of families reporting safety concerns intervention versus baseline was 1.6 (1.0-2.6) overall, 2.6 (1.3-5.4) for those with < college education, and 3.1 (1.3-7.3) in the COVID-19-era subgroup. Safety concerns reported via mobile tool (34.6% of enrolled parents) included 42 medical errors, 43 nonsafety-related quality issues, 11 hazards, and 4 other. 15% of mobile tool concerns were also detected with voluntary incident reporting. CONCLUSIONS: Family safety-reporting was unchanged overall after implementing a mobile reporting tool, though reporting increased among families with lower educational attainment and during the COVID-19 pandemic. The tool identified many events not otherwise captured by staff-only voluntary incident reporting. Hospitals should proactively engage families in reporting to improve safety, quality, and equity.

Applying Coproduction Methods to Research, Clinical Care, Quality Improvement, and Education in PHM.

Coproduction-actively collaborating with key partners and end-users toward a shared goal-challenges the traditional medical hierarchy. Each partner brings unique perspectives, knowledge, expertise, values, and preferences. In pediatric hospital medicine, coproduction involves collaborating with partners often excluded from research, clinical care, quality improvement, and medical education, including patients/families, nurses, and trainees. This article describes strategies for applying coproduction, using multiple pediatric coproduction initiatives as case examples, including efforts of the Patient and Family Centered I-PASS Study Group over the past decade to apply coproduction to studies to reduce harmful medical errors and implement family-centered rounds communication interventions. We describe how coproduction can be applied to (1) research (eg, codesigning instruments, measuring patient-reported outcomes), (2) clinical care (eg, improving treatment effectiveness, shared decision-making), (3) quality improvement (eg, measuring and improving adherence to intervention components), and (4) medical education (eg, training families, nurses, and trainees about communication, providing disease-specific education). Successful coproduction involves attention to diversity, equity, inclusion, engagement, compensation, and team management. Coproduction can lead to higher quality, safer, more equitable care, improved content development and delivery, refined methods and implementation, and more salient learning for all.

Communicating With Spanish-Speaking Families of Hospitalized Children With Medical Complexity.

BACKGROUND AND OBJECTIVES: Hospitalized families who use languages other than English (LOE) for care encounter unique communication challenges, as do children with medical complexity (CMC). We sought to better understand communication challenges and opportunities to improve care of families who use LOE from the perspectives of hospital staff and Spanish-speaking parents of CMC. METHODS: This qualitative project involved secondary analysis of transcripts from a study on family safety reporting at 2 quaternary care children's hospitals and additional primary data collection (interviews) of staff and parents. Bilingual researchers conducted audio-recorded, semistructured interviews with staff and Spanish-speaking parents of CMC during/after hospitalization. We professionally transcribed and translated interviews and developed, iteratively refined, and validated a codebook. Three independent researchers coded interviews using qualitative descriptive methodology and identified emerging themes through thematic analysis. RESULTS: We coded 49 interviews (13 parents, 11 physicians, 13 nurses, 6 allied health professionals, 6 leaders). Five themes emerged: (1) assumptions and bias regarding specific groups who use LOE for care, (2) importance of trust and relationships, (3) importance of language-concordant care, (4) workarounds to address communication challenges, and (5) the "double-edged" sword of technology. Participant-suggested strategies to improve communication included increasing interpreter access for parents and staff, optimizing technology use, and minimizing bias and assumptions through training. CONCLUSIONS: Parents of CMC and staff identified challenges and opportunities related to communicating with hospitalized families who use LOE for care. Solutions to improve communication and safety for these families should be attuned to needs of all parties involved.

Implementing a Family-Centered Rounds Intervention Using Novel Mentor-Trios.

BACKGROUND AND OBJECTIVES: Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites. METHODS: Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents. RESULTS: We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged. CONCLUSIONS: Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected.

Thematic Analysis of Parental Experiences of Patients' Orthognathic Surgery.

Orthognathic surgery often requires extensive orthodontic preparation and a prolonged postoperative recovery that can be stressful for patients and their families. Parents are a primary source of support for patients; accordingly, a better understanding of the parents' experience of orthognathic surgery can help inform clinical care. Using a prospective cross-sectional qualitative study design, 4 focus groups (2 English and 2 Spanish; mean length 65 min) were held with parents of patients who had completed orthognathic surgery for class II/III malocclusion. Thematic content analysis of the group transcriptions was conducted. Participants were 10 mothers and 3 fathers of 12 children (50% with cleft lip/palate) ages 17 to 23 who completed LeFort I (41.7%), LeFort I with bilateral sagittal split osteotomy (BSSO; 41.7%), or BSSO (16.7%) within the prior 3 to 16 months. Themes fit within a chronological framework: (1) Preparing for Surgery included their larger health context, anticipating surgery, surgery preparation by team and family, and religious faith; (2) Challenges after Surgery consisted of complications, pain, frustration, nutritional challenges, parental anxiety, activity changes, sleep, breathing issues, swelling, and unanticipated aspects of surgery; and (3) Supports after Surgery were nutritional support, appreciation of medical team, postoperative improvements, appearance changes, communicating, supporting patient, and patient coping. Parents also offered advice for families and medical teams. Surgeons and other providers who are part of orthognathic surgical preparation can implement recommendations based on parental experiences to increase patient and family readiness for surgery by providing early education, assisting with advocacy, focusing on nutrition, and supporting coping.

How and why might interprofessional patient- and family-centered rounds improve outcomes among healthcare teams and hospitalized patients? A conceptual framework informed by scoping and narrative literature review methods.

Poor communication within healthcare contributes to inefficiencies, medical errors, conflict, and other adverse outcomes. A promising model to improve outcomes resulting from poor communication in the inpatient hospital setting is Interprofessional Patient- and Family-Centered rounds (IPFCR). IPFCR brings two or more health professions together with hospitalized patients and families as part of a consistent, team-based routine to share information and collaboratively arrive at a daily plan of care. A growing body of literature focuses on implementation and outcomes of IPFCR to improve healthcare quality and team and patient outcomes. Most studies report positive changes following IPFCR implementation. However, conceptual frameworks and theoretical models are lacking in the IPFCR literature and represent a major gap that needs to be addressed to move this field forward. The purpose of this two-part review is to propose a conceptual framework of how IPFCR works. The goal is to articulate a framework that can be tested in subsequent research studies. Published IPFCR literature and relevant theories and frameworks were examined and synthesized to explore how IPFCR works, to situate IPFCR in relation to existing models and frameworks, and to postulate core components and underlying causal mechanisms. A preliminary, context-specific, conceptual framework is proposed illustrating interrelationships between four core components of IPFCR (interprofessional approach, intentional patient and family engagement, rounding structure, shared development of a daily care plan), improvements in communication, and better outcomes.

In their own words: Safety and quality perspectives from families of hospitalized children with medical complexity.

BACKGROUND: Children with medical complexity (CMC) experience adverse events due to multiorgan impairment, frequent hospitalizations, subspecialty care, and dependence on multiple medications/equipment. Their families are well-versed in care and can help identify safety/quality gaps to inform improvements. Although previous studies have shown families identify important safety/quality gaps in hospitals, studies of inpatient safety/quality experience of CMC and their families are limited. To address this gap and identify otherwise unrecognized, family-prioritized areas for improving safety/quality of CMC, we conducted a secondary qualitative analysis of safety reporting surveys among families of CMC. OBJECTIVE: Explore safety reports from families of hospitalized CMC to identify areas to improve safety/quality. DESIGNS, SETTINGS AND PARTICIPANTS: We analyzed free-text responses from predischarge safety reporting surveys administered to families of CMC at a quaternary children's hospital from April 2018 to November 2020. Using a qualitative descriptive approach, we categorized responses into standard clinical categories. Three team members inductively generated an initial codebook to apply iteratively to responses. Reviewers coded responses collaboratively, resolved discrepancies through consensus, and generated themes. MAIN OUTCOME AND MEASURES: Outcomes: family-reported areas of safety/quality improvement. MEASURES: pre-discharge family surveys. RESULTS: Two hundred and eight/two hundred and thirty-seven (88%) families completed surveys; 83 families offered 138 free-text safety responses about medications, feeds, cares, and other categories. Themes included unmet expectations of hospital care/environment, lack of consistency, provider-patient communication lapses, families' expertise about care, and the value of transparency. CONCLUSION: To improve care of CMC and their families, hospitals can manage expectations about hospital limitations, improve consistency of care/communication, acknowledge family expertise, and recognize that family-observed quality concerns can have safety implications. Soliciting family input can help hospitals improve care in meaningful, otherwise unrecognized ways.

Parent Experiences with the Process of Sharing Inpatient Safety Concerns for Children with Medical Complexity: A Qualitative Analysis.

OBJECTIVE: To describe the process of identifying and reporting inpatient safety concerns from the perspective of parents of children with medical complexity (CMC). METHODS: We conducted a secondary analysis of qualitative data from semi-structured interviews with 31 English and Spanish-speaking parents of CMC at two tertiary children's hospitals. Interviews lasted 45-60 minutes and were audio-recorded, translated, and transcribed. Three researchers inductively and deductively coded transcripts using an iteratively refined codebook with validation by a fourth researcher. Thematic analysis was used to develop a conceptual model of the process of inpatient parent safety reporting. RESULTS: We identified four steps illustrating the process of inpatient parent safety concern reporting 1) parent recognizing concern, 2) parent reporting concern, 3) staff/hospital response continuum, and 4) parent feelings of validation/invalidation. Many parents endorsed that they were the first to catch a safety concern and were identified as unique reporters of safety information. Parents typically described reporting their concerns verbally and in real-time to the person they felt could quickly remedy the situation. There was a spectrum of validation. Some parents reported their concerns were not acknowledged and addressed, which led them to feel overlooked, disregarded, or judged. Others reported their concerns were acknowledged and addressed, resulting in parents feeling heard and seen and often leading to changes in clinical care. CONCLUSIONS: Parents described a multi-step process of reporting safety concerns during hospitalization and a spectrum of staff response and validation. These findings can inform family-centered interventions that support safety concern reporting in the inpatient setting.

Medication affordability discussions with older adults in primary care.

Introduction: Cost is a major barrier to medication accessibility. While a minority of adults experience problems affording their medications, older adults are particularly vulnerable due to increased polypharmacy and fixed incomes.Clinicians can help reduce cost-related non-adherence and improve medication affordability; however, opportunities to improve affordability are often missed due to failure of the patient or clinician to discuss the issue. Objective: Identify the incidence and resolution of cost-related conversations between patients and clinicians during primary care visits. Methods: We conducted this quality improvement project at a primary care office. Student pharmacists observed in-person encounters with patients ≥65 years of age and documented the incidence of cost-related conversations and who initiated the conversation. After the visit, they asked if the patient had affordability issues. Patients and clinicians were blinded to the study purpose and hypothesis. Results: Students observed 79 primary care visits. Cost conversations (medication or non-medication related) occurred in 37% (29/79) of visits. Having concerns about affordability did not impact the likelihood of conversation about non-medication related healthcare costs (RR = 1.21 95% CI 0.35-4.19, p = 0.67) or medication related costs (RR = 0.86 95% CI 0.13-5.65, p = 1.0). Conclusion: Our results indicated that cost conversations did not routinely occur at our site. Failure to discuss costs, especially for patients with underlying cost concerns, may lead to cost related non-adherence and worse outcomes.

Primary Intensivists and Nurses for Long-Stay Patients: A Survey of Practices and Perceptions at Academic PICUs.

OBJECTIVES: To determine the prevalence of the utilization of primary intensivists and primary nurses for long-stay patients in large, academic PICU and ascertain how these practices are operationalized and perceived. DESIGN: A cross-sectional survey. SETTING: U.S. PICUs with accredited Pediatric Critical Care Medicine fellowships. SUBJECTS: One senior physician and one senior nurse at each institution. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Separate but largely analogous questionnaires for intensivists and nurses were created using an iterative process to enhance content/face validity and readability. Sixty-seven intensivists (representing 93% of the 72 institutions with fellowship programs and their PICUs) and 59 nurses (representing 82%) responded. Twenty-four institutions utilize primary intensivists; 30 utilize primary nurses; and 13 utilize both. Most institutions use length of stay and/or other criteria (e.g., medical complexity) for eligibility. Commonly, not all patients that meet eligibility criteria receive primaries. Primary providers are overwhelmingly volunteers, and often only a fraction of providers participate. Primary intensivists at a large majority (>75%) of institutions facilitate information sharing and decision-making, attend family/team meetings, visit patients/families regularly, and are otherwise available upon request. Primary nurses at a similar majority of institutions provide consistent bedside care, facilitate information sharing, and attend family/team meetings. A large majority of respondents thought that primary intensivists increase patient/family satisfaction, reduce their stress, improve provider communication, and reduce conflict, whereas primary nurses similarly increase patient/family satisfaction. More than half of respondents shared that these practices can sometimes require effort (e.g., time and emotion), complicate decision-making, and/or reduce staffing flexibility. CONCLUSIONS: Primary practices are potential strategies to augment rotating PICU care models and better serve the needs of long-stay and other patients. These practices are being utilized to varying extents and with some operationalization uniformity at large, academic PICUs.

Group Concept Mapping Conceptualizes High-Quality Care for Long-Stay Pediatric Intensive Care Unit Patients and Families.

OBJECTIVE: To describe and conceptualize high-quality care for long-stay pediatric intensive care unit (PICU) patients using group concept mapping (GCM). STUDY DESIGN: We convened an expert panel to elucidate domains of high-quality care for this growing patient population for which transitory care models fail to meet their needs. Thirty-one healthcare professionals and 7 parents of patients with previous prolonged PICU hospitalizations comprised a diverse, interprofessional multidisciplinary panel. Participants completed the prompt "For PICU patients and families experiencing prolonged lengths of stay, high quality care from the medical team includes ______", with unlimited free text responses. Responses were synthesized into individual statements, then panelists sorted them by idea similarity and rated them by perceived importance. Statement analysis using GCM software through GroupWisdom generated nonoverlapping clusters representing domains of high-quality care. RESULTS: Participants submitted 265 prompt responses representing 313 unique ideas, resulting in 78 final statements for sorting and rating. The resultant cluster map best representing the data contained 8 domains: (1) Family-Centered Care and Shared Decision Making, (2) Humanizing the Patient, (3) Clinician Supports and Resources, (4) Multidisciplinary Coordination of Care, (5) Family Well-Being, (6) Anticipatory Guidance and Care Planning, (7) Communication, and (8) Continuity of Care. CONCLUSIONS: GCM empowered a panel of healthcare professionals and parents to explicitly describe and conceptualize high-quality care for patients and families experiencing prolonged PICU stays. This information will aid the effort to address shortcomings of transitory PICU care models.

Continuity Strategies for Long-Stay PICU Patients: Consensus Statements From the Lucile Packard Foundation PICU Continuity Panel.

OBJECTIVES: To develop consensus statements on continuity strategies using primary intensivists, primary nurses, and recurring multidisciplinary team meetings for long-stay patients (LSPs) in PICUs. PARTICIPANTS: The multidisciplinary Lucile Packard Foundation PICU Continuity Panel comprising parents of children who had prolonged PICU stays and experts in several specialties/professions that care for children with medical complexity in and out of PICUs. DESIGN/METHODS: We used modified RAND Delphi methodology, with a comprehensive literature review, Delphi surveys, and a conference, to reach consensus. The literature review resulted in a synthesized bibliography, which was provided to panelists. We used an iterative process to generate draft statements following panelists' completion of four online surveys with open-ended questions on implementing and sustaining continuity strategies. Panelists were anonymous when they voted on revised draft statements. Agreement of 80% constituted consensus. At a 3-day virtual conference, we discussed, revised, and re-voted on statements not reaching or barely reaching consensus. We used Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of the evidence and rate the statements' strength. The Panel also generated outcome, process, and balancing metrics to evaluate continuity strategies. RESULTS: The Panel endorsed 17 consensus statements in five focus areas of continuity strategies (Eligibility Criteria, Initiation, Standard Responsibilities, Resources Needed to Implement, Resources Needed to Sustain). The quality of evidence of the statements was low to very low, highlighting the limited evidence and the importance of panelists' experiences/expertise. The strength of the statements was conditional. An extensive list of potential evaluation metrics was generated. CONCLUSIONS: These expert/parent-developed consensus statements provide PICUs with novel summaries on how to operationalize, implement, and sustain continuity strategies for LSP, a rapidly growing, vulnerable, resource-intensive population in PICUs.

Family, nurse, and physician beliefs on family-centered rounds: A 21-site study.

BACKGROUND: Variation exists in family-centered rounds (FCR). OBJECTIVE: We sought to understand patient/family and clinician FCR beliefs/attitudes and practices to support implementation efforts. DESIGNS, SETTINGS AND PARTICIPANTS: Patients/families and clinicians at 21 geographically diverse US community/academic pediatric teaching hospitals participated in a prospective cohort dissemination and implementation study. INTERVENTION: We inquired about rounding beliefs/attitudes, practices, and demographics using a 26-question survey coproduced with family/nurse/attending-physician collaborators, informed by prior research and the Consolidated Framework for Implementation Research. MAIN OUTCOME AND MEASURES: Out of 2578 individuals, 1647 (64%) responded to the survey; of these, 1313 respondents participated in FCR and were included in analyses (616 patients/families, 243 nurses, 285 resident physicians, and 169 attending physicians). Beliefs/attitudes regarding the importance of FCR elements varied by role, with resident physicians rating the importance of several FCR elements lower than others. For example, on adjusted multivariable analysis, attending physicians (odds ratio [OR] 3.0, 95% confidence interval [95% CI] 1.2-7.8) and nurses (OR 3.1, 95% CI 1.3-7.4) were much more likely than resident physicians to report family participation on rounds as very/extremely important. Clinician support for key FCR elements was higher than self-reported practice (e.g., 88% believed family participation was important on rounds; 68% reported it often/always occurred). In practice, key elements of FCR were reported to often/always occur only 23%-70% of the time. RESULT: Support for nurse and family participation in FCR is high among clinicians but varies by role. Physicians, particularly resident physicians, endorse several FCR elements as less important than nurses and patients/families. The gap between attitudes and practice and between clinician types suggests that attitudinal, structural, and cultural barriers impede FCR.

Patient and Family-Centered I-PASS SCORE Program: Resident and Advanced Care Provider Training Materials.

Introduction: Patient and family-centered rounds (PFCRs) are an important element of family-centered care often used in the inpatient pediatric setting. However, techniques and best practices vary, and faculty, trainees, nurses, and advanced care providers may not receive formal education in strategies that specifically enhance communication on PFCRs. Methods: Harnessing the use of structured communication, we developed the Patient and Family-Centered I-PASS Safer Communication on Rounds Every Time (SCORE) Program. The program uses a standardized framework for rounds communication via the I-PASS mnemonic, principles of health literacy, and techniques for patient/family engagement and bidirectional communication. The resident and advanced care provider training materials, a component of the larger SCORE Program, incorporate a flipped classroom approach as well as interactive exercises, simulations, and virtual learning options to optimize learning and retention via a 90-minute workshop. Results: Two hundred forty-six residents completed the training and were evaluated on their knowledge and confidence regarding key elements of the curriculum. Eighty-eight percent of residents agreed/strongly agreed that after training they could activate and engage families and all members of the interprofessional team to create a shared mental model; 90% agreed/strongly agreed that they could discuss the roles/responsibilities of various team members during PFCRs. Discussion: The Patient and Family-Centered I-PASS SCORE Program provides a structured framework for teaching advanced communication techniques that can improve provider knowledge of and confidence with engaging and communicating with patients/families and other members of the interprofessional team during PFCRs.

Intervention, individual, and contextual determinants to high adherence to structured family-centered rounds: a national multi-site mixed methods study.

BACKGROUND: Effective communication in transitions between healthcare team members is associated with improved patient safety and experience through a clinically meaningful reduction in serious safety events. Family-centered rounds (FCR) can serve a critical role in interprofessional and patient-family communication. Despite widespread support, FCRs are not utilized consistently in many institutions. Structured FCR approaches may prove beneficial in increasing FCR use but should address organizational challenges. The purpose of this study was to identify intervention, individual, and contextual determinants of high adherence to common elements of structured FCR in pediatric inpatient units during the implementation phase of a large multi-site study implementing a structured FCR approach. METHODS: We performed an explanatory sequential mixed methods study from September 2019 to October 2020 to evaluate the variation in structured FCR adherence across 21 pediatric inpatient units. We analyzed 24 key informant interviews of supervising physician faculty, physician learners, nurses, site administrators, and project leaders at 3 sites using a qualitative content analysis paradigm to investigate site variation in FCR use. We classified implementation determinants based on the Consolidated Framework for Implementation Research. RESULTS: Provisional measurements of adherence demonstrated considerable variation in structured FCR use across sites at a median time of 5 months into the implementation. Consistent findings across all three sites included generally positive clinician beliefs regarding the use of FCR and structured rounding approaches, benefits to learner self-efficacy, and potential efficiency gains derived through greater rounds standardization, as well as persistent challenges with nurse engagement and interaction on rounds and coordination and use of resources for families with limited English proficiency. CONCLUSIONS: Studies during implementation to identify determinants to high adherence can provide generalizable knowledge regarding implementation determinants that may be difficult to predict prior to implementation, guide adaptation during the implementation, and inform sustainment strategies.

Family Safety Reporting in Hospitalized Children With Medical Complexity.

BACKGROUND AND OBJECTIVES: Hospitalized children with medical complexity (CMC) are at high risk of medical errors. Their families are an underutilized source of hospital safety data. We evaluated safety concerns from families of hospitalized CMC and patient/parent characteristics associated with family safety concerns. METHODS: We conducted a 12-month prospective cohort study of English- and Spanish-speaking parents/staff of hospitalized CMC on 5 units caring for complex care patients at a tertiary care children's hospital. Parents completed safety and experience surveys predischarge. Staff completed surveys during meetings and shifts. Mixed-effects logistic regression with random intercepts controlling for clustering and other patient/parent factors evaluated associations between family safety concerns and patient/parent characteristics. RESULTS: A total of 155 parents and 214 staff completed surveys (>89% response rates). 43% (n = 66) had ≥1 hospital safety concerns, totaling 115 concerns (1-6 concerns each). On physician review, 69% of concerns were medical errors and 22% nonsafety-related quality issues. Most parents (68%) reported concerns to staff, particularly bedside nurses. Only 32% of parents recalled being told how to report safety concerns. Higher education (adjusted odds ratio 2.94, 95% confidence interval [1.21-7.14], P = .02) and longer length of stay (3.08 [1.29-7.38], P = .01) were associated with family safety concerns. CONCLUSIONS: Although parents of CMC were infrequently advised about how to report safety concerns, they frequently identified medical errors during hospitalization. Hospitals should provide clear mechanisms for families, particularly of CMC and those from disadvantaged backgrounds, to share safety concerns. Actively engaging patients/families in reporting will allow hospitals to develop a more comprehensive, patient-centered view of safety.

Association of Patient and Family Reports of Hospital Safety Climate With Language Proficiency in the US.

Importance: Patients with language barriers have a higher risk of experiencing hospital safety events. This study hypothesized that language barriers would be associated with poorer perceptions of hospital safety climate relating to communication openness. Objective: To examine disparities in reported hospital safety climate by language proficiency in a cohort of hospitalized children and their families. Design, Setting, and Participants: This cohort study conducted from April 29, 2019, through March 1, 2020, included pediatric patients and parents or caregivers of hospitalized children at general and subspecialty units at 21 US hospitals. Randomly selected Arabic-, Chinese-, English-, and Spanish-speaking hospitalized patients and families were approached before hospital discharge and were included in the analysis if they provided both language proficiency and health literacy data. Participants self-rated language proficiency via surveys. Limited English proficiency was defined as an answer of anything other than "very well" to the question "how well do you speak English?" Main Outcomes and Measures: Primary outcomes were top-box (top most; eg, strongly agree) 5-point Likert scale ratings for 3 Children's Hospital Safety Climate Questionnaire communication openness items: (1) freely speaking up if you see something that may negatively affect care (top-box response: strongly agree), (2) questioning decisions or actions of health care providers (top-box response: strongly agree), and (3) being afraid to ask questions when something does not seem right (top-box response: strongly disagree [reverse-coded item]). Covariates included health literacy and sociodemographic characteristics. Logistic regression was used with generalized estimating equations to control for clustering by site to model associations between openness items and language proficiency, adjusting for health literacy and sociodemographic characteristics. Results: Of 813 patients, parents, and caregivers who were approached to participate in the study, 608 completed surveys (74.8% response rate). A total of 87.7% (533 of 608) of participants (434 [82.0%] female individuals) completed language proficiency and health literacy items and were included in the analyses; of these, 14.1% (75) had limited English proficiency. Participants with limited English proficiency had lower odds of freely speaking up if they see something that may negatively affect care (adjusted odds ratio [aOR], 0.26; 95% CI, 0.15-0.43), questioning decisions or actions of health care providers (aOR, 0.19; 95% CI, 0.09-0.41), and being unafraid to ask questions when something does not seem right (aOR, 0.44; 95% CI, 0.27-0.71). Individuals with limited health literacy (aOR, 0.66; 95% CI, 0.48-0.91) and a lower level of educational attainment (aOR, 0.59; 95% CI, 0.36-0.95) were also less likely to question decisions or actions. Conclusions and Relevance: This cohort study found that limited English proficiency was associated with lower odds of speaking up, questioning decisions or actions of providers, and being unafraid to ask questions when something does not seem right. This disparity may contribute to higher hospital safety risk for patients with limited English proficiency. Dedicated efforts to improve communication with patients and families with limited English proficiency are necessary to improve hospital safety and reduce disparities.