James S. Todd Memorial Research Award

Improving Hospital Safety for Children: Strategies to Engage Parents in Bedside Rounds

Elizabeth Cox, MD, PhD, University of Wisconsin School of Medicine and Public Health

The overarching goal of this work is to improve safety for hospitalized children by identifying strategies to address the barriers and facilitators of family engagement in bedside rounds. Each year 7 million US children are hospitalized, which places them at risk for alarming rates of medical error. Engaging families as partners has the potential to improve safety by reducing the likelihood of medication errors and improving hand hygiene to decrease healthcare-associated infections. To facilitate family engagement, experts recommend conducting rounds at the child’s bedside with the family present. To improve safety, family engagement is needed in all three key tasks of the healthcare encounter—building a relationship with the healthcare team, exchanging information, and making decisions about diagnoses, testing, and treatment. Yet research suggests that engaging families to improve safety meets with reluctance from both healthcare team members and families. Bedside rounds represent a consistent venue to engage families in the care of hospitalized children, yet no studies have systematically identified and addressed barriers and facilitators of family engagement during bedside rounds as a means to improve safety. This project will identify strategies that address common barriers and facilitators of family engagement during bedside rounds, using established human factors and systems engineering approaches.

Our data will consist of videos of each day of bedside rounds for 30 enrolled families from our inpatient units, resulting in a sample of ~72 bedside rounds videos. Using a stimulated recall technique where families and healthcare team members become the analysts of their own videotaped bedside rounds sessions, participants will identify barriers and facilitators of family engagement during rounds, then generate strategies to directly address these. Audiotapes of these stimulated recall sessions will be coded using directed content analysis to identify and categorize barriers and facilitators as well as the strategies to address these. Since the project began four months ago, 10 stimulated recall sessions have been conducted and the analysis of that data is beginning. Future work outside the scope of this proposal will subject the identified strategies to evaluation and prioritization before 1) incorporating them into the institution’s planned interventions to enhance family engagement in rounds and 2) evaluating the interventions’ impact on safety for hospitalized children.

NPSF Board Grant

Analysis of CPOE-related errors reported to USP’s MEDMARX error reporting system

Gordon Schiff, MD, Brigham and Women’s Hospital/ Harvard Medical School

Computerized ordering of medications is a priority for improving the safety of medication use, reflecting solid evidence demonstrating its ability to significantly reduce errors. However, like any new technology, along with expected benefits come both predictable as well as unanticipated consequences. In addition to the spread of CPOE over the past decade there have been considerable patient safety efforts invested in developing systems for medical and medication error reporting. One of the more prominent and successful of these initiatives has been the United States Pharmacopeia (USP) MEDMARX medication error reporting system (now owned and administered by QUANTROS) which has collected more than 2 million medication errors from more than 800 hospitals and health systems. Beginning in 2003 MEDMARX added “Computerized Prescriber Order Entry as a Cause of the Error” as one of the variables in their error reporting tool. The number of CPOE-related reports in the database has now grown to more than 50,000. This project will conduct an in-depth analysis of these reports by an experienced team of patient safety pharmacist and physician researchers.

To contribute to this goal of more deeply understanding CPOErelated medication error experience the study will undertake the following 5 aims: 1) Statistical analysis of the more than 50,000 medication errors reported as CPOE-related, 2) conduct in-depth qualitative and quantitative review of the report narratives to extract insights from the first-hand reports to better understand the nature and mechanism of the reported CPOE-related errors and how better designed systems might have prevented them, 3) test the vulnerability of leading CPOE systems to these actual errors by attempting to replicate (on test patients) selected recurring errors identified in the reports, examining these CPOE systems’ susceptibility to (or ability to prevent) such errors, 4) make recommendations based on lessons learned for safer CPOE use, and 5) harvest lessons for better understanding the strengths and limitations of error reporting and error reports and functions of reporting systems such as MEDMARX to make recommendations for enhancing its use and usefulness.