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

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Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study
The BMJ ( IF 93.6 ) Pub Date : 2018-12-05 00:00:00 , DOI: 10.1136/bmj.k4764
Alisa Khan _{1,

2} , Nancy D Spector _{3,

4} , Jennifer D Baird ₅ , Michele Ashland ₆ , Amy J Starmer _{1,

2} , Glenn Rosenbluth _{7,

8} , Briana M Garcia _{2,

7} , Katherine P Litterer ₉ , Jayne E Rogers ₁₀ , Anuj K Dalal _{1,

11} , Stuart Lipsitz _{1,

11} , Catherine S Yoon ₁₁ , Katherine R Zigmont ₁₁ , Amy Guiot _{12,

13} , Jennifer K O'Toole _{12,

13} , Aarti Patel _{14,

15} , Zia Bismilla _{16,

17} , Maitreya Coffey _{16,

17} , Kate Langrish _{18,

19} , Rebecca L Blankenburg _{20,

21} , Lauren A Destino _{20,

21} , Jennifer L Everhart _{20,

21} , Brian P Good _{22,

23} , Irene Kocolas _{22,

23} , Rajendu Srivastava _{22,

23} , Sharon Calaman _{3,

4} , Sharon Cray ₂₄ , Nicholas Kuzma _{3,

4} , Kheyandra Lewis _{3,

4} , E Douglas Thompson _{3,

4} , Jennifer H Hepps _{25,

26} , Joseph O Lopreiato ₂₅ , Clifton E Yu _{25,

26} , Helen Haskell ₂₇ , Elizabeth Kruvand _{28,

29} , Dale A Micalizzi ₃₀ , Wilma Alvarado-Little _{31,

31} , Benard P Dreyer _{32,

33} , H Shonna Yin _{32,

34} , Anupama Subramony _{35,

36} , Shilpa J Patel _{37,

38} , Theodore C Sectish _{1,

2} , Daniel C West _{7,

8} , Christopher P Landrigan _{1,

2,

39}

Affiliation

Harvard Medical School, Boston, MA, USA.
Department of Medicine and Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.
Drexel University College of Medicine, Philadelphia, PA, USA.
Department of Pediatrics, St Christopher's Hospital for Children, Philadelphia, PA, USA.
Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, CA, USA.
Family-Centered Care Department, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
University of California San Francisco School of Medicine, San Francisco, CA, USA.
Department of Pediatrics, Benioff Children's Hospital, San Francisco, CA, USA.
Office of Experience, Boston Children's Hospital, Boston, MA, USA.
Inpatient Medicine, Boston Children's Hospital, Boston, MA, USA.
Center for Patient Safety Research, Division of General Medicine, Department of Medicine at Brigham and Women's Hospital, Boston, MA, USA.
University of Cincinnati College of Medicine, Cincinnati, OH, USA.
Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
University of California San Diego School of Medicine, San Diego, CA, USA.
Division of Pediatric Hospital Medicine, Rady Children's Hospital San Diego, San Diego, CA, USA.
Pediatrics, University of Toronto, Toronto, ON, Canada.
Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.
Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
Division of Pediatric Hospital Medicine, Hospital for Sick Children, Toronto, ON, Canada.
Stanford School of Medicine, Palo Alto, CA, USA.
Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
University of Utah School of Medicine, Salt Lake City, UT, USA.
Department of Pediatrics, Primary Children's Hospital, Salt Lake City, UT, USA.
Family Advisory Council, St Christopher's Hospital for Children, Philadelphia, PA, USA.
Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA.
Walter Reed National Military Medical Center, Bethesda, MD, USA.
Mothers Against Medical Error, Columbia, SC, USA.
Family Partner Program, St Louis Children's Hospital, St Louis, MO, USA.
St Louis Children's Hospital, St Louis, MO, USA.
The Justin's HOPE Project, Task Force for Global Health, Decatur, GA, USA.
New York State Department of Health, New York, NY, USA.
New York University School of Medicine, New York, NY, USA.
Division of Developmental-Behavioral Pediatrics, New York University Langone Medical Center, New York, NY, USA.
Departments of Pediatrics and Population Health at New York University Langone Medical Center, New York, NY, USA.
Cohen Children's Medical Center, New York, NY, USA.
Hofstra Northwell School of Medicine, Queens, NY, USA.
University of Hawaii John A Burns School of Medicine, Honolulu, HI, USA.
Hawai'i Pacific Health, Honolulu, HI, USA.
Brigham and Women's Hospital, Boston, MA, USA.

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.

中文翻译：

实施共同制作的以家庭为中心的沟通计划后的患者安全：干预研究前后的多中心

目的确定实施干预后医疗错误、家庭经历和沟通过程是否有所改善，以规范以家庭为中心的医疗保健提供者与家庭的沟通结构。
设计前瞻性、多中心干预前后的研究。
设置在七个北美医院，17 2014年12月儿科住院部到1月3日2017年
参加所有患者收治研究单位（3106接诊病人13171天）; 2148 名父母或照顾者、435 名护士、203 名医学生和 586 名住院医师。
干涉家庭、护士和医生共同制定了一项干预措施，以标准化医疗保健提供者与家庭在查房时的沟通（“以家庭为中心的查房”），其中包括在床边查房中进行结构化、高可靠性的沟通，强调健康素养、家庭参与和双向沟通；结构化的、书面的实时回合摘要；针对医疗保健提供者的正式培训计划；以及支持团队合作、实施和流程改进的策略。
主要观察指标医疗错误（主要结果），包括有害错误（可预防的不良事件）和非有害错误，使用泊松回归和按地点聚类的广义估计方程建模；家庭经历；和沟通过程（例如，家庭参与轮次）。错误是通过既定的系统监测方法来衡量的，包括家庭安全报告。
结果总体医疗差错率（每 1000 个患者日）没有变化（干预前 41.2（95% 置信区间 31.2 至 54.5）v干预后35.8（26.9 至 47.7），P=0.21），但有害错误（可预防）不良事件）减少了 37.9%（20.7（15.3 至 28.1）v12.9（8.9 至 18.6），P=0.01）干预后。不可预防的不良事件也减少（12.6（8.9 至 17.9）v 5.2（3.1 至 8.8），P=0.003）。家庭报告体验的 25 个组成部分中有 6 个的顶盒（例如，“优秀”）评级得到改善；没有人恶化。以家庭为中心的轮次发生得更频繁（72.2%（53.5% 至 85.4%）vs 82.8%（64.9% 至 92.6%），P=0.02）。家庭参与 55.6%（32.9% 至 76.2%）v 66.7%（43.0% 至 84.1%），P=0.04）和护士参与（20.4%（7.0% 至 46.6%）v 35.5%（17.0% 至 59.6%）， P=0.03) 轮次改善。在轮次开始时表达担忧的家庭（18.2%（5.6% 至 45.3%）v 37.7%（17.6% 至 63.3%），P=0.03）和复读计划（4.7%（0.7% 至 25.2%）v26.5%（12.7% 至 7.3%），P=0.02）增加。学员教学和轮次的持续时间没有显着变化。
结论在家庭、护士和医生共同制作的以家庭为中心的巡视中实施结构化沟通干预后，虽然总体错误没有变化，但有害的医疗错误减少了，家庭体验和沟通过程得到了改善。以家庭为中心的护理流程可以提高护理的安全性和质量，而不会对教学或轮次持续时间产生负面影响。
试验注册ClinicalTrials.gov NCT02320175。

更新日期：2018-12-06

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