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Parents can detect, contribute to, or be affected by critical events during a child's hospitalization

From the June 16, 2011 issue

Problem: Today, parents are often permitted around-the-clock visiting hours to stay with their hospitalized children, even in neonatal and pediatric intensive care units (ICUs). Many parents take advantage of this option and remain with their children as much as possible. For an ill child, this can be comforting and provides an important emotional benefit. At the same time, parents may be carefully watching and interacting with healthcare professionals, and observing the specialized equipment at their child’s bedside, including infusion pumps, IV lines, and drainage systems. A study published by Frey et al. in 2009 suggests that parents who stay with their hospitalized children are inevitably involved in safety issues.(1) In particular, the study showed that parents can help detect critical (harmful or potentially harmful) events precipitated by healthcare professionals. However, the study also showed that parents can contribute to a critical event and are often adversely affected by a critical event. 

The study was conducted over a 5½ year period in a neonatal-pediatric intensive care unit and a neonatal intermediate care unit in a university children’s hospital. During the first 2 years of the study, visiting hours for parents were limited to afternoons and evenings; morning visitations were not allowed and overnight stays were strongly discouraged. Around-the-clock visiting hours were permitted during the last 3½ years of the study.

During the span of the study, a total of 2,494 critical events were recorded; 101 of these events directly involved parents. In 18 cases, a parent contributed to the critical event. In 11 cases, a parent detected a critical event. In the remaining 72 cases, a parent was one of the affected individuals. For each event, the actual and potential severity was determined to be minor (requiring no interventions), moderate (requiring routine therapy available outside a critical care unit), or major (requiring therapeutic interventions specific to critical care units, or resulted in death). 

In the group of critical events that involved parents (n=101), medication events (38%) and line disconnections/reconnections (28%) were most prevalent. In the group of critical events that did not involve parents (n=2,393), events involving medications were again most prevalent (33%), but issues with line disconnections/reconnections (2.7%) were significantly lower. Most events precipitated by parents and subsequently detected by healthcare professionals caused actual harm determined to be of moderate severity, and some events had the potential to cause a high severity of harm. On the other hand, critical events detected by parents did not cause actual harm, although the events had the potential to cause harm of moderate severity. Further details about the study follow.

Parents detecting safety problems
The most common safety problems detected by parents involved medication errors, tubes or drains that became disconnected, and respiratory distress. Examples include:

  • A mother who realized that a physician had prescribed a five-fold overdose of carvedilol for her child (5 mg BID instead of 1 mg BID)
  • A mother who noticed the wrong weight listed on her child’s medical record used for prescribing medications
  • Parents who called attention to their child’s respiratory distress or failure.

It took parents between 0-70 hours (median 10 hours) to detect a critical event precipitated by a healthcare professional. This suggests that without the parents’ interventions, some critical events might have continued without correction. The authors determined the potential harm from continuation of the detected critical events to be severe in 4 cases, moderate in 6 cases, and minor in 1 case. All of the events detected by parents occurred only after around-the-clock visiting hours were made available. This observation suggests that it is easier for parents to detect safety problems if they spend more hours at their child’s bedside, observing and participating in their care.

Parents contributing to safety problems
The most common safety problems precipitated by parents involved the disconnection of tubes and drains, medication errors, and physical trauma. Examples include:

  • A mother accidentally disconnected a central venous line while breast feeding her baby
  • A mother accidentally disconnected a pleural drain while holding her infant
  • A father fell off a chair with his child on his lap.

All of the disconnected tubes and drains happened in young infants, from 4 days to 1½ years old. It took healthcare professionals between 0-29 hours (median 0.25 hours) to detect a critical event precipitated by a parent. The authors note that this finding suggests that healthcare professionals are providing appropriate supervision of parents and hospitalized children. Most of these events caused moderate harm (10 cases) before being detected. In all but one event, quick discovery of the problems averted severe harm.

Parents affected by safety events
The most common types of problems affecting parents involved miscommunication and feeding mix-ups. One can expect parents to be emotionally affected by most critical events that involve their children, especially those leading to harm. However, with some critical events, parents were directly affected in ways that were not anticipated. One of the most common examples included mothers who were subjected to viral testing because their breast milk was accidentally fed to another child. Failures such as this increase parental stress during a child’s hospitalization.

Safe Practice Recommendations: Consider the following recommendations to strengthen the partnership between the treatment team and a hospitalized child’s parents, prevent parental contribution to critical events, promote parental detection of errors, and protect the hospitalized child from harm.

Educate parents. Teach parents about the disease/condition, medical tests, and treatment plan for their hospitalized child. Specifically tell parents about all the medications their child is receiving, the prescribed doses (including the fact that it differs from the dose taken at home, if applicable), potential side effects, and when and how they are given. Write down important information for parents to reference as needed. Parents who know what to expect can help recognize when something is not right.

Update parents. Provide parents with timely and comprehensive updates regarding their children in language they understand. Some children’s hospitals encourage parents to be part of “family-centered” rounds, allowing them to gain a better understanding of their child’s total treatment plan and current status since the entire medical team is available to answer questions and address concerns.

Anticipate involvement. Be aware of increasingly independent parental involvement in the medical care of their children. A 2001 study by Hurst showed that parents continuously analyze hospital procedures and develop an action plan to protect their babies.(2) A fundamental challenge for mothers in this study was to increase their position of authority relative to the medical team, thereby safeguarding their babies. Parents may intervene during the care of their children, which can lead to prevention and detection of a critical event, or contribution to a critical event despite good intentions. Close parental involvement in the child’s treatment plan should be encouraged, supervised, and monitored. 

Encourage parents to speak up. Encourage parents to report any concerns or worries they have regarding their child’s care. Frey et al. suggests periodically asking parents these two questions: “Are there aspects of your child’s care that you find concerning?” and “What do you worry about when you leave your child?” Encourage parents to keep asking questions or voicing concerns until they receive an answer with which they are comfortable and fully understand. Remind parents that they know their child better than anyone on the medical team; thus, communication of their observations is extremely important.

Respond to parents’ queries appropriately. Parents do not want to be labeled as being “difficult” or “demanding;” they fear no one will want to take care of their child if they are perceived this way.(2) Some may even view basic questions or requests for information about their child’s condition as a slight to the medical team’s competence. So, when parents do speak up, healthcare professionals should perceive and reflect their actions in a manner that fosters true collaboration and empowerment, and should encourage and reinforce the parents’ role in making queries by providing thoughtful and complete answers.  

Provide access to a rapid response team. Allow parents to activate a rapid response team if they feel no one is addressing their expressed concerns regarding their child’s condition and/or medical treatment. Instruct parents, upon their child’s admission, regarding the purpose of the rapid response team and how to activate it.

Establish safe handling guidelines. To reduce the risk of tubing disconnections, establish guidelines for safe handling of infants and children with lines and drains, teach these guidelines to parents, and monitor adherence to the guidelines.

Teach parents not to reconnect tubes. Orient parents to the tubes or drains attached to their child. Teach them about the dangers of reconnecting tubes and drains themselves and how to call for immediate help from a healthcare professional if their child’s tubes or drains become dislodged or disconnected.

References:
1) Frey B, Ersch J, Bernet V, Baenziger O, et al. Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit. QualSaf Health Care. 2009;18(6):446-449.

2) Hurst I. Vigilant watching over: mothers’ actions to safeguard their premature babies in the newborn intensive care unit. J Perinat Neonatal Nurs. 2001;15(3):39-57.
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