Parents Can Detect, Contribute to, or be Affected by Critical Events During a Child's Hospitalization

ISMP Medication Safety Alert 

In This Article

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.

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