Parents the “Missing Link” in Patient Safety Efforts

Hello everybody-

A fascinating new report on the role of parents in pediatric patient safety efforts is published in the July 30 issue of Journal of Hospital Medicine (paid registration required). A summary of the article is available through the University of Michigan.
Beth A. Tarini, MD, MS, assistant professor of pediatrics at the University of Michigan Medical School, and her co-authors Paula Lozano, MD, MPH, and Dimitri A. Christakis, MD, MPH, of the Seattle Children’s Hospital Research Institute, looked into parents’ perceptions of medical errors, patient safety, and communication. They found that nearly two-thirds of parents felt that they had to closely oversee their children’s hospital care to prevent a medical error from happening.
Interestingly, parents who reported a higher level of confidence in communicating with the medical team were less likely to be worried by the potential for medical errors.
Dr. Tarini draws an important conclusion: “We need to address parents’ concerns about errors and find ways to make them feel comfortable talking to us about their child’s care. Parents are an underutilized resource in our efforts to prevent medical errors.”
I can’t echo Dr. Tarini’s sentiment enough. While some parents are trained medical professionals, most are not. But parents- because of their close relationships with their children- are often able to sense important but subtle changes in their children’s conditions. Parents are more than visitors. They have the potential to meaningfully contribute to their children’s medical care. Time has come to harness that potential.
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It All Comes Back to Communication

In the nearly five years that I have been participating in this patient safety movement, I have met thousands of wonderful healthcare providers. I have visited hospitals all over the country. I have sat and listened to dozens of patient safety conferences and grand rounds. I have learned big words like nosocomial infections.

Through it all I have told Josie’s story and every step of the way I have tried my best to inspire caregivers to incorporate patient safety best practices into their everyday experience on the job. I have looked and listened, and have been amazed at all of the good I see, while also being confused as to why things can’t happen faster and why 98,000 people still continue to die from medical errors every year.

The thing that really continues to amaze me is the communication issue. Josie died because people didn’t listen. They didn’t listen to me, and they didn’t listen to each other. I can’t tell you how many stories I have on my computer from families who have been affected by medical errors, and there always seems to be a common thread, “They didn’t listen.”

Correct me if I’m wrong. Doesn’t the Joint Commission report that over 60% of all sentinel events are due to a breakdown in communication? I am not a doctor or a nurse. I am not at the bedside, and I am not an expert in the field of patient safety; however it seems to me that if people communicated better we’d all be safer. I believe in high tech solutions. It is where we are heading, but wouldn’t we get more bang for our buck if we communicated better?

I was in Pennsylvania a few months ago at a wonderful hospital by the name Abington Memorial. I was presenting at their Grand Rounds. After the presentation, I was lucky enough to join them on their Patient Safety rounds. The team consisted of two nurses, a doctor, and a board member. I was struck by two things:

The first was the presence of the board member. There is a lot of talk these days about getting board members involved, especially when it comes to safety and quality. It was so great to see first hand a hospital that was doing just that.

The second thing that struck me- Every unit we went to, the patient safety officer would ask the nursing team on the floor a question:

“If you could have anything you wanted on your floor to keep patients safe what would it be?”

Each floor had variations on the same response:

“I wish we could get into the doctors’ heads.”
“I wish we were more like a team.”
“I wish we communicated better.”

That is what they wanted. They did not ask for fancy equipment or the latest in technology. They wanted to understand what the doctors were thinking. They wanted better communication between the nurses and the doctors. The thing that amazes me even more is that I hear this everywhere I go. Communication- and it is not just between the doctors and the nurses. It is between the patients, their families and those who are caring for them.

It seems so simple, but I am learning that changing behavior is not an easy thing to do. I don’t know what it takes, maybe time, maybe another generation, hopefully not more deaths.

I will tell you one thing. The board member that day heard that message loud and clear and I bet she shared what she learned with her fellow board members, at least I hope she did.

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