Our work advances the field of pediatric patient safety by adapting and validating a measurement model for parent views of safety climate in a children’s hospital. We find that the previously validated models for staff survey data fit parent data well for domains that are visible to parents--overall perceptions of safety, handoffs and transitions, and communication openness. Such a measure could be useful in taking a patient-centered approach to patient safety and for ensuring safety climate is assessed at the frontline of care, where it most often correlates with safety events.[7
] Further, two of the parent-reported safety climate domains are significantly associated with parent perceptions about needing to watch over care. Specifically, perceived need to watch over care was significantly associated with overall perceptions of safety and with handoffs and transitions. Our findings suggest potential targets to improve hospital safety climate and ultimately perhaps reduce parent burden for watching over care.
Beyond the recognized value of safety climate measures arising from the frontline of care, parent-reported safety climate measures for children’s hospitals are needed for several reasons. Although hospitalized children disproportionately suffer medical errors, existing measures of patient safety are quite limited in their utility for the pediatric inpatient population and often focus on rare, high impact medical errors such as central line infections, more commonly seen in intensive care unit settings. Such measures are poorly suited to smaller institutions and for the general pediatric population, most of whom do not have central lines and in which it may be years before a single event such as a hospital-acquired central line infection is documented. Further, being flexible is a key element of organizations with a strong safety culture.[21
] This flexibility includes deferring to expertise over rank and parents are assuredly the leading experts on their children’s care.
Two other advantages of a parent-reported measure of safety climate arise from the characteristics of the data provided by parents. First, parent response rates to the survey were substantially higher than those of staff surveys.[10
] While this may be because of the research nature of this work, parents may be highly motivated to report about the safety of care provided to their child. Second, parent data is more easily analyzable by hospital unit. In general, hospitalized children and their parents remain on the same unit throughout a hospital stay, barring a deterioration that requires transfer to intensive care services. This is in contrast to the experience of physicians or other staff who may work across multiple units. Understanding safety climate at the unit or service level has been recommended, as safety climates are “local” and analyzing at the institution level may mask opportunities for improving safety.[37
As noted in the AHRQ-commissioned review, healthcare system employees and patients or parents may view safety differently, but both views have value.[39
] In our work, parents rated handoffs and transitions as well as overall perceptions of safety considerably higher than AHRQ national data from hospital staff, which is similar to data from our institution.[40
] Also, the minimum value for staff communication openness was quite high, perhaps reflecting either parents’ reluctance to report negatively about this aspect of care or that staff are careful about interactions that are visible to families. Further, parental experiences with specific aspects of hospital care (e.g., the policies and procedures that could prevent errors) may be limited, affecting their ability to report on these. Future studies might survey staff and patients/parents to examine similarities and differences in perceptions of safety climate. In addition, such studies could examine the responsiveness to change for parental reports of safety climate to understand whether these could be used to assess the impact of intervention to improve pediatric patient safety.
The associations found between parent need to watch over care and safety climate domains suggest potential targets to improve hospital safety climate and ultimately perhaps reduce parent burden for watching over care. Specifically, the likelihood that a parent felt the need to watch over care was significantly greater when parents held less positive views of our children’s hospital’s overall safety climate or our handoffs and transitions. To address overall perceptions of safety, the focus might include optimizing procedures and systems for preventing mistakes and making these procedures and systems visible to parents. Also, this domain’s items tap into parent need to see a commitment to safety that exceeds our drive to get the work done. Thus, focusing on ensuring families feel safe may be especially crucial when our hospital is busiest. For handoffs and transitions, the focus likely resides in demonstrating that staff are imparting important information during these critical times. For example, performing nursing shift changes at the bedside with the parent may reduce parent need to watch over care.[41
] Since this study, our institution has implemented this type of nursing handoff at the bedside. Also, being explicit with parents about anticipated changes in healthcare team members (physicians or nurses) and perhaps doing these handoffs with the parent present could reduce parent need to watch over care.
Through our adjusted analyses, we were also able to consider how characteristics of the parent, the child, and the hospitalization impacted parent perceptions of safety. Specifically, having a child hospitalized for a breathing problem was associated with greater parent need to watch over care, compared to being hospitalized for any other reason. In addition, parent education significantly influenced parents’ beliefs about whether they needed to watch over care to ensure mistakes weren’t made. Taken together, these findings support the critical need for considering a broad array of patient socio-demographics, hospitalization characteristics, and institutional factors as covariates in pediatric patient safety research, especially when using parent-reported data.
As with all observational studies, certain limitations should be considered. First, as a single institution study, the findings may not generalize to children’s hospitals broadly. The sample size may have underpowered some comparisons. Also, variability in the communication openness domain scores was less than for the other two domains, perhaps limiting our ability to detect significant associations. One possible explanation for the limited variability in communication openness measures may be the relatively large number of highly educated parents in our study. In addition, our population has relatively few minority families, so we may under-represent the views of those who are more likely to experience adverse events[43
] and also less likely to report these.[44
] Future work through a multi-institutional collaborative could examine these types of questions, as well as safety climate broadly.
Due to IRB requirements, we have limited data on the parents who refused to learn about the study or did not consent. Given that absent or sleeping parents constituted our most common reason for study exclusion, our findings could be biased toward more negative views of safety climate and greater need to watch over care (i.e., parents who felt the need to watch over care were more likely to remain with their child). However, our recruitment rate for eligible parents was high, exceeding that of the prior similar study.[33
] Because of the need to limit the survey to a reasonable numbers of items, we also lack data on concepts such as general beliefs about the safety of the healthcare system broadly and on prior experiences with medical error, which could influence views about safety.
In summary, we find that parent responses to our adapted version of the AHRQ Hospital Survey on Patient Safety Culture display good model fit with the domains described in the original instrument. Understanding patient experiences with care provides additional information for improving care, as these experiences are linked to outcomes such as satisfaction.[45
] Efforts are underway to understand parent experiences with their hospitalized children’s healthcare, adapting the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) for use with this population, although this tool does not focus on hospital safety.[46
] Having a tool to assess parent perceptions of safety climate in a children’s hospital has numerous advantages and can act as a supplement to staff data. In addition, we were able to identify specific opportunities to improve our safety climate in an effort to help parents feel burden for watching over their child’s care to ensure mistakes aren’t made.