According to the Joint Commission, the leading root causes of hospital sentinel events are communication-related.1 Communication contributes not only to patient and physician understanding of medical problems and the risks and benefits of treatment but also impacts outcomes, such as satisfaction2 and adherence.3 Consequently, it is not surprising that miscommunications are associated with care quality and patient safety problems.4 Although there is a large body of literature examining communication between patients and providers,5 fewer researchers have considered communication among parents and providers.6–8 In this issue of Hospital Pediatrics, Khan et al9 have put forth one of the first pediatric studies to evaluate parent-provider miscommunications and their association with parent-reported medical errors in the hospital setting.
In this single-center study, investigators examined the rates and types of parent-provider miscommunications and their association with top-box experience and parent-reported errors in a cohort of hospitalized children. Over 18 months, 471 English-speaking parents of children on 2 medical units were surveyed on discharge from the hospital about miscommunications with their child’s care team (defined as physicians and nurses) and possible negative consequences of these miscommunications. Attending physicians caring for these children on their discharge from the hospital completed a similar survey. Of 406 parent respondents, 15.3% reported miscommunications with their care team during their hospital stay. Parents of children with longer lengths of stay and those who were nonpublicly insured were more likely to report miscommunications. In addition, parents reporting miscommunications were significantly less likely to report top-box experiences and more likely to report errors than those not reporting miscommunications. Within parent-physician respondent dyads, only 3.7% of attending physicians reported miscommunications, significantly fewer than their parent counterpart. However, both parents and physicians reported that providing conflicting information to families was the main source of miscommunication, followed by concerns about delayed provisioning of information and families being upset about the way communication occurred.
One limitation of a study such as this one is the reliance on participant recollection, which introduces possible recall bias. Recall bias, a systematic error caused by differences in accuracy or completeness of the recollections retrieved, represents a possible threat to the validity of studies using self-reported data. Parent participants were asked to fill out a survey on weekday evenings, which may have also resulted in selection bias. Because of limited interpreter services during evenings, investigators also excluded non-English-speaking parents, who may report different rates of miscommunication.
Nonetheless, the findings from this study are valuable and inform important next steps aimed at tackling communication-related issues in the pediatric hospital setting. Results suggest that miscommunications are prevalent and may be underrecognized by discharging physicians. Although responsible for the child’s care, a discharging physician is present for a small and variable amount of time during the child’s overall care experience. It is unlikely that he or she knows about all communication-related issues that may have occurred. Hospitals house patients, families, and a multitude of health care team members who interact within the context of a complex system. Even during a relatively short hospitalization, patients and their parents may meet a large number of hospital employees on different floors, all rotating through different shifts. These care providers have different roles and experiences and provide patient care by using various tools and technologies within the organizational and physical setting of the hospital, all of which may impact communication.10 Thus, understanding the perspectives of a variety of health care team members and how they communicate with patients and parents within the context of their day-to-day work will be important in addressing communication breakdowns. As patients and parents bring unique and important perspectives regarding communication and safety,11 every effort should also be made to integrate them into the design, implementation, and evaluation of communication improvement efforts.
Although miscommunication rates are high, there is progress being made to improve patient- and parent-provider communication in the inpatient setting. The Joint Commission now requires hospitals to provide standardized handoff strategies and use translators for non-English-speaking patients.12 The Accreditation Council for Graduate Medical Education mandates that residency programs teach and assess residents’ interpersonal and communication skills during training.13 The American Academy of Pediatrics endorses patient- and family-centered care delivery practices,14 such as bringing the team together at the bedside to discuss hospital care plans with parents during family-centered rounds.
Opportunities still exist to improve the timeliness of clinical information provided to parents in the inpatient setting. For example, with the near ubiquitous use of electronic health records, we now have the ability to share real-time clinical information electronically with parents of hospitalized children.15 Along with providing information, this technology also allows for bidirectional electronic communication between parents and inpatient health care team members through secure-messaging. However, this technology is just a tool and will not solve all communication-related problems. Care will need to be taken to assure it does not lead to further miscommunications.
Communication plays a major role in hospital care quality and safety. Results from Khan et al’s9 most recent study reveal that miscommunications among parents of hospitalized children and their care teams are common, underestimated by discharging physicians, and associated with parent-reported errors and lower ratings of hospital experience. Parents and health care team members should be engaged as partners in designing hospital systems and processes to improve communication and, thus, care quality and safety.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the Clinical and Translational Science Award (CTSA) program through the National Center for Advancing Translational Sciences (NCATS) grant UL1TR000427. Dr Hoonakker's involvement in the study was also partially supported by National Science Foundation (NSF) grant CMMI 1536987. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
- ↵The Joint Commission. Sentinel events statistics. 2017. Available at: www.jointcommission.org/SentinelEvents/Statistics/. Accessed April 6, 2017
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- ↵The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care: a roadmap for hospitals. 2010. Available at: http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf. Accessed April 6, 2017
- ↵Accreditation Council of Graduate Medical Education. Common program requirements. 2017. Available at: http://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements. Accessed April 6, 2017
- ↵Committee on Hospital Care and Institute for Patient- and Family-Centered Care. Patient- and family-centered care and the pediatrician’s role. Pediatrics. 2012;129(2):394–404
- Copyright © 2017 by the American Academy of Pediatrics