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.

Developing a Responsive Transferable Model for Delivering Large-Scale Simulation Education to Inpatient Nursing Staff.

Implementing large-scale nursing continuing development programs for bedside staff can be operationally challenging. The aim of this project was to establish a sustainable simulation education program that is incorporated into staff nurses' work schedules and provides provisions to accommodate patient assignment coverage. This article describes the planning, implementation, and evaluation of a simulation program that was successfully delivered to 89% of nurses employed on four inpatient units at an academic medical center.

Reduced Postdischarge Incidents After Implementation of a Hospital-to-Home Transition Intervention for Children With Medical Complexity.

OBJECTIVES: Prior research suggests that errors occur frequently for patients with medical complexity during the hospital-to-home transition. Less is known about effective postdischarge communication strategies for this population. We aimed to assess rates of 30-day (1) postdischarge incidents and (2) readmissions and emergency department (ED) visits before and after implementing a hospital-to-home intervention. METHODS: We conducted a prospective intervention study of children with medical complexity discharged at a children's hospital from April 2018 to March 2020. A multistakeholder team developed a bundled intervention incorporating the I-PASS handoff framework including a postdischarge telephone call, restructured discharge summary, and handoff communication to outpatient providers. The primary outcome measure was rate of postdischarge incidents collected via electronic medical record review and family surveys. Secondary outcomes were 30-day readmissions and ED visits. RESULTS: There were 199 total incidents and the most common were medication related (60%), equipment issues (15%), and delays in scheduling/provision of services (11%). The I-PASS intervention was associated with a 36.4% decrease in the rate of incidents per discharge (1.51 versus 0.95, P = 0.003). There were fewer nonharmful errors and quality issues after intervention (1.27 versus 0.85 per discharge, P = 0.02). The 30-day ED visit rate was significantly lower after intervention (12.6% versus 3.4%, per 100 discharges, P = 0.05). Thirty-day readmissions were 15.8% versus 10.2% postintervention (P = 0.32). CONCLUSIONS: A postdischarge communication intervention for patients with medical complexity was associated with fewer postdischarge incidents and reduced 30-day ED visits. Standardized postdischarge communication may play an important role in improving quality and safety in the transition from hospital-to-home for vulnerable populations.

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.

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.

Medication Order Errors at Hospital Admission Among Children With Medical Complexity.

OBJECTIVES: We sought to characterize the nature and prevalence of medication order errors (MOEs) occurring at hospital admission for children with medical complexity (CMC), as well as identify the demographic and clinical risk factors for CMC experiencing MOEs. METHODS: Prospective cohort study of 1233 hospitalizations for CMC from November 1, 2015, to October 31, 2016, at 2 children's hospitals. Medication order errors at admission were identified prospectively by nurse practitioners and a pharmacist through direct patient care. The primary outcome was presence of at least one MOE at hospital admission. Statistical methods used included χ2 test, Fisher exact tests, and generalized linear mixed models. RESULTS: Overall, 6.1% (n = 75) of hospitalizations had ≥1 MOE occurring at admission, representing 112 total identified MOEs. The most common MOEs were incorrect dose (41.1%) and omitted medication (34.8%). Baclofen and clobazam were the medications most commonly associated with MOEs. In bivariable analyses, MOEs at admission varied significantly by age, assistance with medical technology, and numbers of complex chronic conditions and medications (P < 0.05). In multivariable analysis, patients receiving baclofen had the highest adjusted odds of MOEs at admission (odds ratio, 2.2 [95% confidence interval, 1.2-3.8]). CONCLUSIONS: Results from this study suggest that MOEs are common for CMC at hospital admission. Children receiving baclofen are at significant risk of experiencing MOEs, even when orders for baclofen are correct. Several limitations of this study suggest possible undercounting of MOEs during the study period. Further investigation of medication reconciliation processes for CMC receiving multiple chronic, home medications is needed to develop effective strategies for reducing MOEs in this vulnerable population.

Children with medical complexity: A concept analysis.

AIM: The aim of this paper is to conduct a concept analysis on the term, "children with medical complexity." BACKGROUND: Children with medical complexity (CMC) describes pediatric patients with chronic, sustained acuity; however, there is a lack of consensus in the literature regarding its exact meaning, characteristics, and implications. DESIGN: This analysis relied upon the framework described by Walker and Avant. DATA SOURCE: The CINAHL, MEDLINE, and PubMed databases were queried from April 2020 to December 2020 with an initial search of the literature for the keyword, "children with medical complexity" and other associated terms, such as "pediatric medical complexity" and "nursing care of children with medical complexity." REVIEW METHODS: This analysis will explore the concept of CMC and its significance, attributes, antecedents, and consequences. RESULTS: This investigation revealed that CMC are a growing population of pediatric patients who have one or more complex chronic conditions that affect multiple body systems, experience functional limitations, require extensive care coordination from multiple providers, and are dependent upon life-sustaining medical technology. CONCLUSIONS: The findings can serve as a foundation for future work advancing the understanding of the topic of CMC.

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study

OBJECTIVE: To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds. DESIGN: Prospective, multicenter before and after intervention study. SETTING: Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017. PARTICIPANTS: All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents. INTERVENTION: Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds ("family centered rounds"), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement. MAIN OUTCOME MEASURES: Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting. RESULTS: The overall rate of medical errors (per 1000 patient days) was unchanged (41.2 (95% confidence interval 31.2 to 54.5) pre-intervention v 35.8 (26.9 to 47.7) post-intervention, P=0.21), but harmful errors (preventable adverse events) decreased by 37.9% (20.7 (15.3 to 28.1) v 12.9 (8.9 to 18.6), P=0.01) post-intervention. Non-preventable adverse events also decreased (12.6 (8.9 to 17.9) v 5.2 (3.1 to 8.8), P=0.003). Top box (eg, "excellent") ratings for six of 25 components of family reported experience improved; none worsened. Family centered rounds occurred more frequently (72.2% (53.5% to 85.4%) v 82.8% (64.9% to 92.6%), P=0.02). Family engagement 55.6% (32.9% to 76.2%) v 66.7% (43.0% to 84.1%), P=0.04) and nurse engagement (20.4% (7.0% to 46.6%) v 35.5% (17.0% to 59.6%), P=0.03) on rounds improved. Families expressing concerns at the start of rounds (18.2% (5.6% to 45.3%) v 37.7% (17.6% to 63.3%), P=0.03) and reading back plans (4.7% (0.7% to 25.2%) v 26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly. CONCLUSIONS: Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds. TRIAL REGISTRATION: ClinicalTrials.gov NCT02320175.

Issues Identified by Postdischarge Contact after Pediatric Hospitalization: A Multisite Study.

BACKGROUND: Many hospitals are considering contacting hospitalized patients soon after discharge to help with issues that arise. OBJECTIVE: To (1) describe the prevalence of contactidentified postdischarge issues (PDI) and (2) assess characteristics of children with the highest likelihood of having a PDI. DESIGN, SETTING, PATIENTS: A retrospective analysis of hospital-initiated follow-up contact for 12,986 children discharged from January 2012 to July 2015 from 4 US children's hospitals. Contact was made within 14 days of discharge by hospital staff via telephone call, text message, or e-mail. Standardized questions were asked about issues with medications, appointments, and other PDIs. For each hospital, patient characteristics were compared with the likelihood of PDI by using logistic regression. RESULTS: Median (interquartile range) age of children at admission was 4.0 years (0-11); 59.9% were nonHispanic white, and 51.0% used Medicaid. The most common reasons for admission were bronchiolitis (6.3%), pneumonia (6.2%), asthma (5.1%), and seizure (4.9%). Twenty-five percent of hospitalized children (n=3263) reported a PDI at contact (hospital range: 16.0%-62.8%). Most (76.3%) PDIs were related to follow-up appointments (eg, difficulty getting one); 20.8% of PDIs were related to medications (eg, problems filling a prescription). Patient characteristics associated with the likelihood of PDI varied across hospitals. Older age (age 10-18 years vs <1 year) was significantly (P<.001) associated with an increased likelihood of PDI in 3 of 4 hospitals. CONCLUSIONS: PDIs were identified often through hospital-initiated follow-up contact. Most PDIs were related to appointments. Hospitals caring for children may find this information useful as they strive to optimize their processes for follow-up contact after discharge.

Clinician Perceptions of the Importance of Hospital Discharge Components for Children.

BACKGROUND: Discharging hospitalized children involves several different components, but their relative value is unknown. We assessed which discharge components are perceived as most and least important by clinicians. METHODS: March and June of 2014, we conducted an online discrete choice experiment (DCE) among national societies representing 704 nursing, physician, case management, and social work professionals from 46 states. The DCE consisted of 14 discharge care components randomly presented two at a time for a total of 28 choice tasks. Best-worst scaling of participants' choices generated mean relative importance (RI) scores for each component, which allowed for ranking from least to most important. RESULTS: Participants, regardless of field or practice setting, perceived "Discharge Education/Teach-Back" (RI 11.1 [95% confidence interval, CI: 11.0-11.3]) and "Involve the Child's Care Team" (RI 10.6 [95% CI: 10.4-10.8]) as the most important discharge components, and "Information Reconciliation" (RI 4.1 [95% CI: 3.9-4.4]) and "Assigning Roles/Responsibilities of Discharge Care" (RI 2.8 [95% CI: 2.6-3.0]) as least important. CONCLUSIONS: A diverse group of pediatric clinicians value certain components of the pediatric discharge care process much more than others. Efforts to optimize the quality of hospital discharge for children should consider these findings.

Nurse Practitioner Lead Pediatric Baclofen Pump Program: Impact on Safety and Quality of Care.

Children with cerebral palsy experience spasticity that can be debilitating and cause significant pain and contractures. Intrathecal baclofen (ITB) therapy can help relieve this spasticity and improve the quality of life for these patients, but it comes with risk. Withdrawal from the medication in case of abrupt discontinuation of delivery can be life-threatening. Regular maintenance of the system is mandatory. Having a program in place to manage the device and support patients helps to ensure their safety. Toward this end, we developed a program with a nurse practitioner (NP) leader to secure the safety and quality of care for patients using ITB therapy. As the program grew, the NP role as an expert in the care and management of ITB pumps became essential to the safety and care of these patients. In addition to the basic outpatient and inpatient management of the baclofen pump, the NP developed a detailed educational program for the patients and leads the quality and safety initiative for the program. The NP is also in a unique position to have intimate knowledge of the patient's condition and build a strong relationship with the patient/family. The NP is able to use this knowledge and relationship as concerns arise that could be related to the ITB therapy. This has greatly improved the safety and quality of care for patients using ITB therapy at our institution.

Parent-Provider Miscommunications in Hospitalized Children.

BACKGROUND: Miscommunications lead to medical errors and suboptimal hospital experience. Parent-provider miscommunications are understudied. OBJECTIVES: (1) Examine characteristics of parent-provider miscommunications about hospitalized children, (2) describe associations among parent-provider miscommunications, parent-reported errors, and hospital experience, and (3) compare parent and attending physician reports of parent-provider miscommunications. METHODS: Prospective cohort study of 471 parents of 0- to 17-year-old medical inpatients in a pediatric hospital between May 1, 2013 and October 1, 2014. At discharge, parents reported parent-provider miscommunication and type (selecting all applicable responses), overall experience, and errors during hospitalization. During discharge billing, the attending physicians (n = 52) of a subset of patients (n = 217) also reported miscommunications, enabling comparison of parent and attending physician reports. We used logistic regression to examine characteristics of parent-reported miscommunications; McNemar's test to examine associations between miscommunications, errors, and top-box (eg, "excellent") experience; and generalized estimating equations to compare parent- and attending physician-reported miscommunication rates. RESULTS: Parents completed 406 surveys (86.2% response rate). 15.3% of parents (n = 62) reported miscommunications. Parents of patients with nonpublic insurance (odds ratio: 1.99; 95% confidence interval: 1.03-3.85) and longer lengths of stay (odds ratio: 1.12; 95% confidence interval: 1.02-1.23) more commonly reported miscommunications. Parents reporting miscommunications were 5.3 times more likely to report errors and 78.6% less likely to report top-box overall experience (P < .001 for both). Among patients with both parent and attending physician surveys, 16.1% (n = 35) of parents and 3.7% (n = 8) of attending physicians reported miscommunications (P < .001). Both parents and attending physicians attributed miscommunications most often to family receipt of conflicting information. CONCLUSIONS: Parent-provider miscommunications were associated with parent-reported errors and suboptimal hospital experience. Parents reported parent-provider miscommunications more often than attending physicians did.

Nursing-led Home Visits Post-hospitalization for Children with Medical Complexity.

PURPOSE: Hospital discharge for children with medical complexity (CMC) can be challenging for families. Home visits could potentially benefit CMC and their families after leaving the hospital. We assessed the utility of post-discharge home visits to identify and address health problems for recently hospitalized CMC. DESIGN AND METHODS: A prospective study of 36 CMC admitted to a children's hospital from 4/15/2015 to 4/14/2016 identified with a possible high risk of hospital readmission and offered a post-discharge home visit within 72h of discharge. The visit was staffed by a hospital nurse familiar with the child's admission. The home visit goals were to reinforce education of the discharge plan, assess the child's home environment, and identify and address any problems or issues that emerged post-discharge. RESULTS: The children's median age was 6years [interquartile range (IQR) 2-18]. The median distance from hospital to their home was 38miles (IQR 8-78). All (n=36) children had multiple chronic conditions; 89% (n=32) were assisted with medical technology. The nurse identified and helped with a post-discharge problem during every (n=36) visit. Of the 147 problems identified, 26.5% (n=39) pertained to social/family issues (e.g., financial instability), 23.8% (n=35) medications (e.g., wrong dose), 20.4% (n=30) durable medical equipment (e.g., insufficient supply or faulty function), 20.4% (n=30) child's home environment (e.g., unsafe sleeping arrangement), and 8.8% (n=13) child's health (e.g., unresolved health problem). CONCLUSIONS: Home visits helped identify and address post-discharge issues that occurred for discharged CMC. PRACTICAL IMPLICATIONS: Hospitals should consider home visits when optimizing discharge care for CMC.

Parent and Provider Experience and Shared Understanding After a Family-Centered Nighttime Communication Intervention.

OBJECTIVE: To assess parent and provider experience and shared understanding after a family-centered, multidisciplinary nighttime communication intervention (nurse-physician brief, family huddle, family update sheet). METHODS: We performed a prospective intervention study at a children's hospital from May 2013 to October 2013 (preintervention period) and May 2014 to October 2014 (postintervention period). Participants included 464 parents, 176 nurses, and 52 resident physicians of 582 hospitalized 0- to 17-year-old patients. Pre- versus postintervention, we compared parent/provider top-box scores (eg, "excellent") for experience with communication across several domains; and level of agreement (shared understanding) between parent, nurse, and resident reports of patients' reason for admission, overnight medical plan, and overall medical plan, as rated independently by blinded clinician reviewers (agreement = 74.7%, kappa = .60). RESULTS: Top-box parent experience improved for 1 of 4 domains: Experience and Communication With Nighttime Doctors (23.6% to 31.5%). Top-box provider experience improved for all 3 domains, including Communication and Shared Understanding With Families (resident rated, 16.5% to 35.1%; nurse rated, 32.2% to 37.9%) and Experience, Communication, and Shared Understanding With Other Providers (resident rated, 20.3% to 35.0%; nurse rated, 14.7% to 21.5%). Independently rated shared understanding remained unchanged for most domains but improved for parent-nurse composite shared understanding (summed agreement for reason for admission, overall plan, and overnight plan; 36.2% to 48.2%) and nurse-resident shared understanding regarding reason for admission (67.1% to 71.2%) and regarding overall medical plan (45.0% to 58.6%). All P <.05. CONCLUSIONS: A family-centered, multidisciplinary nighttime communication intervention was associated with improvements in some, but not all, domains of parent/provider experience and shared understanding, particularly provider experience and nurse-family shared understanding. The intervention was promising but requires further refinement.

From development to implementation-A smartphone and email-based discharge follow-up program for pediatric patients after hospital discharge.

The purpose of this case study was to investigate opportunities to electronically enhance the transitions of care for both patients and providers and to describe the process of development and implementation of such tools. We describe the current challenges and fragmentation of care for pediatric patients and families being discharged from inpatient stays, and review barriers to change in practice. Care transitions vary in the complexity of the clinical and social scenarios and no one-size-fits-all approach works for every patient, provider or hospital system. A substantial challenge that providers who are designing and implementing digital tools for patients surrounds the complexity in building such tools to apply to such broad populations. Our case study provides a framework using a multidisciplinary approach, brainstorming and rapid digital prototyping to build an in-house electronic discharge follow-up platform. In describing this process, we review design and implementation measures that may further support digital tool development in other areas.

Communication and Shared Understanding Between Parents and Resident-Physicians at Night.

BACKGROUND AND OBJECTIVE: Communication breakdowns between members of the health care team compromise patient safety and experience. Communication breakdowns with parents, an important but often overlooked part of the health care team, are understudied. Parents may play a particularly important role in nighttime care given decreased staffing and inadequate transitions of care at night. We studied communication breakdowns evidenced by lack of shared understanding between parents and night-team residents about the reason for admission and care plan. METHODS: We conducted a prospective cohort study of parents (n = 286) and night-team senior residents (n = 34) from May 1, 2013 to October 31, 2013. Parents and residents rated communication and described patients' reason for admission, overall plan, and overnight plan. Two physician investigators independently reviewed (κ = 0.63) resident-parent dyads, assigned subsequently dichotomized 4-point overall agreement scores, and rated plan complexity. Using clustered logistic regression, we evaluated relationships among demographics, plan complexity, and shared understanding. We also examined resident and parent perceptions of shared understanding. RESULTS: We analyzed data from 257 parent-resident dyads. Among these, 45.1% were rated as lacking shared understanding (agreement score = 1 or 2). In multivariate analysis, higher plan complexity (P < .001) and length of stay (P = .002) were associated with lack of shared understanding; lower parental education was a borderline predictor (P = .05). When surveyed, parents and residents reported that they shared an understanding with one another about care plans in 86.0% and 73.1% of cases, respectively. CONCLUSIONS: Parents and night-team residents frequently lack shared understanding. Family-centered care initiatives to improve parent-provider communication and shared understanding may help empower parents as partners in safe and high-quality nighttime care.

Parent-Reported Errors and Adverse Events in Hospitalized Children.

IMPORTANCE: Limited data exist regarding the incidence and nature of patient- and family-reported medical errors, particularly in pediatrics. OBJECTIVE: To determine the frequency with which parents experience patient safety incidents and the proportion of reported incidents that meet standard definitions of medical errors and preventable adverse events (AEs). DESIGN, SETTING, AND PARTICIPANTS: We conducted a prospective cohort study from May 2013 to October 2014 within 2 general pediatric units at a children's hospital. Included in the study were English-speaking parents (N = 471) of randomly selected inpatients (ages 0-17 years) prior to discharge. Parents reported via written survey whether their child experienced any safety incidents during hospitalization. Two physician reviewers classified incidents as medical errors, other quality issues, or exclusions (κ = 0.64; agreement = 78%). They then categorized medical errors as harmful (ie, preventable AEs) or nonharmful (κ = 0.77; agreement = 89%). We analyzed errors/AEs using descriptive statistics and explored predictors of parent-reported errors using bivariate statistics. We subsequently reviewed patient medical records to determine the number of parent-reported errors that were present in the medical record. We obtained demographic/clinical data from hospital administrative records. MAIN OUTCOMES AND MEASURES: Medical errors and preventable AEs. RESULTS: The mean (SD) age of the 383 parents surveyed was 36.6 (8.9) years; most respondents (n = 266) were female. Of 383 parents surveyed (81% response rate), 34 parents (8.9%) reported 37 safety incidents. Among these, 62% (n = 23, 6.0 per 100 admissions) were determined to be medical errors on physician review, 24% (n = 9) were determined to be other quality problems, and 14% (n = 5) were determined to be neither. Thirty percent (n = 7, 1.8 per 100 admissions) of medical errors caused harm (ie, were preventable AEs). On bivariate analysis, children with medical errors appeared to have longer lengths of stay (median [interquartile range], 2.9 days [2.2-6.9] vs 2.5 days [1.9-4.1]; P = .04), more often had a metabolic (14.3% vs 3.0%; P = .04) or neuromuscular (14.3% vs 3.6%; P = .05) condition, and more often had an annual household income greater than $100,000 (38.1% vs 30.1%; P = .06) than those without errors. Fifty-seven percent (n = 13) of parent-reported medical errors were also identified on subsequent medical record review. CONCLUSIONS AND RELEVANCE: Parents frequently reported errors and preventable AEs, many of which were not otherwise documented in the medical record. Families are an underused source of data about errors, particularly preventable AEs. Hospitals may wish to consider incorporating family reports into routine safety surveillance systems.

Discharge Facilitation: An Innovative PNP Role.

Efficient and safe transition from the hospital to the community setting remains a priority in health care. Providers face mounting pressure of both timely discharges and minimizing readmissions, because these factor have an impact on provider reimbursement. Traditionally in academic medical centers, rotating teams of resident physicians have been responsible for discharging inpatients. The acute care pediatric nurse practitioner (PNP), when discharging patients, may arrange follow-up care, prescribe medications, and sign discharge orders, as the resident physician does. Additionally, the PNP is positioned to provide continuity of care and provide detailed discharge teaching and care coordination. The goal of this article is to review the literature pertaining to the nurse practitioner role in discharge facilitation and describe the creation and impact of an innovative nurse practitioner discharge coordinator role at a large urban pediatric medical center where improved discharge times were achieved.

Physician and Nurse Nighttime Communication and Parents' Hospital Experience.

BACKGROUND AND OBJECTIVE: Night teams of hospital providers have become more common in the wake of resident physician duty hour changes. We sought to examine relationships between nighttime communication and parents' inpatient experience. METHODS: We conducted a prospective cohort study of parents (n = 471) of pediatric inpatients (0-17 years) from May 2013 to October 2014. Parents rated their overall experience, understanding of the medical plan, quality of nighttime doctors' and nurses' communication with them, and quality of nighttime communication between doctors and nurses. We tested the reliability of each of these 5 constructs (Cronbach's α for each >.8). Using logistic regression models, we examined rates and predictors of top-rated hospital experience. RESULTS: Parents completed 398 surveys (84.5% response rate). A total of 42.5% of parents reported a top overall experience construct score. On multivariable analysis, top-rated overall experience scores were associated with higher scores for communication and experience with nighttime doctors (odds ratio [OR] 1.86; 95% confidence interval [CI], 1.12-3.08), for communication and experience with nighttime nurses (OR 6.47; 95% CI, 2.88-14.54), and for nighttime doctor-nurse interaction (OR 2.66; 95% CI, 1.26-5.64) (P < .05 for each). Parents provided the highest percentage of top ratings for the individual item pertaining to whether nurses listened to their concerns (70.5% strongly agreed) and the lowest such ratings for regular communication with nighttime doctors (31.4% excellent). CONCLUSIONS: Parent communication with nighttime providers and parents' perceptions of communication and teamwork between these providers may be important drivers of parent experience. As hospitals seek to improve the patient-centeredness of care, improving nighttime communication and teamwork will be valuable to explore.

A framework of pediatric hospital discharge care informed by legislation, research, and practice.

To our knowledge, no widely used pediatric standards for hospital discharge care exist, despite nearly 10 000 pediatric discharges per day in the United States. This lack of standards undermines the quality of pediatric hospital discharge, hinders quality-improvement efforts, and adversely affects the health and well-being of children and their families after they leave the hospital. In this article, we first review guidance regarding the discharge process for adult patients, including federal law within the Social Security Act that outlines standards for hospital discharge; a variety of toolkits that aim to improve discharge care; and the research evidence that supports the discharge process. We then outline a framework within which to organize the diverse activities that constitute discharge care to be executed throughout the hospitalization of a child from admission to the actual discharge. In the framework, we describe processes to (1) initiate pediatric discharge care, (2) develop discharge care plans, (3) monitor discharge progress, and (4) finalize discharge. We contextualize these processes with a clinical case of a child undergoing hospital discharge. Use of this narrative review will help pediatric health care professionals (eg, nurses, social workers, and physicians) move forward to better understand what works and what does not during hospital discharge for children, while steadily improving their quality of care and health outcomes.