1. Rosenberg, Karen


According to this study:


* An intervention designed to improve communication between health care providers and family members may also decrease harmful medical errors and improve the family's experience.



Article Content

The Joint Commission has identified communication failures as a leading cause of the most harmful medical errors. Researchers conducted a multicenter study of pediatric units to determine whether implementation of an intervention designed to standardize communication with parents during hospital rounds would improve patient safety, the family's experience, and communication.


Care processes and outcomes on pediatric units in seven hospitals were assessed before and after implementation of a family-centered intervention, which was designed by a group that included physicians, nurses, and parents. The intervention consisted of a structured, high-reliability communication framework bolstered by health literacy, family engagement, and bidirectional communication.


The authors defined a medical error as a failure in the care process (such as administering penicillin to a patient with a penicillin allergy). They found that the overall rate of medical errors didn't change significantly after implementation of the intervention. By contrast, the number of harmful medical errors (adverse events that were due to error and therefore preventable) was significantly lower; the rate of nonpreventable adverse events (those that were not due to error) also decreased. There was no change in the rate of nonharmful errors.


Ratings on six of 25 items related to the family's experience improved. Family-centered rounds occurred more often, and family and nurse engagement on rounds improved. Frequency of teaching on rounds didn't change after implementation of the intervention.


The authors conclude that the intervention led to observed improvements in patient safety but acknowledge that the results could differ in populations that have lower health literacy than that of the study population.




Khan A, et al. BMJ 2018;363:k4764.