Catching medical errors: Father (and mother) know best

Parents of hospitalized children routinely catch medical errors and preventable adverse events (AEs) that medical professionals miss, a study published online in JAMA Pediatrics found.

Because many of the errors and adverse events were not otherwise documented in the hospital record, the researchers recommended incorporating family reports into routing safety surveillance systems. At this point, families "are an underused source of data about errors, particularly preventable AEs," they concluded.

Researchers surveyed 383 parents, 34 of whom reported 37 safety incidents, according to the study abstract. Of the 37 incidents, physicians later determined 62 percent were medical errors, 24 percent were other quality problems and 14 percent were neither. A subsequent review of medical records identified 57 percent of the parent-reported medical errors.

A full 30 percent of the medical errors caused harm. Children experiencing medical errors had slightly longer hospital stays (2.9 days versus 2.5 days). They were more likely to have had a metabolic or neuromuscular condition.

Preventable errors included a poorly dressed wound contaminated by stool; delays detecting a foreign body left behind after a procedure; an infection from an unused IV catheter, and failure to recognize or treat retention of urine, Reuters reported.

"As anyone who has ever been hospitalized knows, hospitals are very complex places where there are a lot of moving parts, and errors are bound to happen despite all of our best efforts," Alisa Khan, M.D., a pediatrics researcher at Harvard Medical School and Boston Children's Hospital, told Reuters. "I think we--including parents--can all work together to keep children safe."

Parents said communication failures contributed to errors, including inadequate documentation before shift changes, according to Reuters.

Hospitals increasingly are conducting nursing change-of-shift reports at the bedside with the patient and family to improve patient safety and communication, FierceHealthcare previously reported. Doing so "should be viewed as a core safety strategy in hospitals today," contends the Institute for Patient-and-Family-Centered Care, a nonprofit that trains hospitals on bedside shift reporting.

A study released last year found that using a distinct naming convention for infants in the Neonatal Intensive Care Unit could reduce medical errors, FierceHealthcare previously reported. The researchers found that nondistinct names such as Babyboy or Babygirl for babies whose parents haven't get given them names increases the chance that medical orders get mixed up. Adding the mother's first name to the newborn's temporary name reduced near-misses by 36 percent.

To learn more:
- here's the study abstract
- read the Reuters article

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