Patient Safety & Family-Centered Care

Establish policies and practices that reflect the unique needs of pediatric patients to promote patient safety. Recognize that family-centered care is integral to ensuring that patient and family perspectives, choices, knowledge, values, beliefs, and cultural backgrounds are incorporated into the planning and delivery of care.


This flow diagram is designed to help you think about how you would break down this focus area into small steps. The questions in this flow diagram align with the environmental scan worksheet.

PWDC Patient Safety & Family-Centered Care


According to the Institute for Patient- and Family-Centered Care, Patient- and family-centered care is an approach to the planning, delivery, and evaluation of healthcare.[1] Family-centered care should be integrated into all healthcare experiences to support pediatric patients and their families’ physical, psychosocial, emotional, and developmental well-being during a potentially stressful and/or invasive health care event. As an advocate for children, the PECC can:

  • Support a culture of safety that encompasses every interaction with a pediatric patient and their family.
  • Encourage information-sharing to promote participation in medical care decision-making and seek to help family members retain a sense of control during emergency medical care.
  • Provide the opportunity for family presence during medical transport or invasive procedures.

Patient safety encompasses every healthcare worker's interaction with a patient or family, from collecting history, treating a patient, to handoff. A focus on patient safety can help identify processes and opportunities to prevent errors in any of these interactions. By recognizing the value of a family’s knowledge about a patient’s condition, the PECC should engage patients and families.

Current research shows biases can lead to different treatments based on race, age (e.g., young mother), gender, etc. and can result in poorer outcomes. Cognitive bias is defined as a bias that causes misinterpretation of information. This can ultimately lead to medical errors. The first step to prevention of such errors is to reflect and identify the biases we each have developed as a result of our environment or past experiences. Patients and families may also present with their own biases based on past treatment. The PECC can play a major role in developing a process to assess for bias when pediatric safety events occur and continually looking for opportunities to minimize biases.

Testimonials

“We also do a lot of community outreach, safety town injury prevention programs, anything that we can to help make sure the kids in our community are served.” (EMS Agency PECC)

“...In the process of treating a pediatric, we encourage our providers to involve the family as much as they can in the process or the treatment in that sense kind of thing, trying to tell the providers to allow the family if possible to be involved in the treatment and care of the child.” (EMS Agency PECC)

  1. Patient- and Family- Centered Care Defined. Ipfcc.org. https://ipfcc.org/bestpractices/sustainable-partnerships/background/pfcc-defined.html. Accessed February 1, 2021.

1. Culture

Crosscutting Change Strategies

1.1 Develop a process where leaders engage with staff to discuss potential safety threats.

1.2 Promote a “speak-up” culture where staff feels empowered to voice safety concerns.

1.3 Promote a blame-free culture where individuals freely report errors and near-miss events without fear of punishment.

1.4 Promote a culture where families are involved in shared decision-making and there is an attention to children’s pain and anxiety.

Hospital-Based Providers

1.5 Develop a process where leadership routinely performs safety rounds on units, engaging and talking to staff about any safety concerns.

1.6 Develop a process of leader-based rounds where nurse and physician directors round on families to solicit feedback on how they feel pain and anxiety have been addressed as well as an explanation of the care plan to families.

1.7 Utilize a safety culture survey to identify opportunities for improvement in the organization (e.g., AHRQ’s Surveys on Patient Safety Culture-SOPS®).

2. Education & Awareness

Note: Focus Area #5 is specifically dedicated to Care Team Competencies. This driver specifically refers to change strategies that promote patient safety and family-centered care.

Cross-Cutting Change Strategies

2.1 Develop materials that promote education and awareness about the unique physical characteristics, physiologic responses, and psychosocial needs of children with an illness or injury.

2.2 Identify training delivery modality for staff (e.g., a learning management system, PowerPoint slides presented during staff meetings, just-in-time education; peer-to-peer coaching).

2.3 Promote the integration of health literacy concepts and skills, including the use of plain language, the teach-back method, pictograms, and lower-literacy instructions

EMSC State Partnership Programs

2.4 Increase awareness of regional and national safety campaigns with which healthcare practitioners across the care continuum can engage (e.g., National Water Safety Month, Safe Kids®, Stop the Bleed ®).

2.5 Connect with your state/territory EMSC Family Advisory Network (FAN) representative on how best to engage patients and families in your region.

3. Practices & Procedures

Cross-Cutting Change Strategies

3.1 Ensure collection of a full set of vital signs (including temperature, blood pressure, heart rate, respiratory rate, oxygenation via pulse oximetry, and a pain score).

3.2 Utilize distraction techniques/items, education on comfort holds for children, education on adjunctive medications use for any painful procedure (intranasal medication delivery, topical gel for lacerations, topical pain control for IV insertion).

3.3 Develop processes for safe medication administration:

  • use precalculated dosing guidelines for children of all ages. Consider promoting smartphone applications that provide decision support for precalculated doses.
  • promote distraction-free zones for medication preparation
  • practice vigilance for all administered or prescribed medications and consider developing standardized order sets, particularly for high-risk medications, such as opioids and antibiotics
  • implement an independent 2-provider cross-check process for high-alert medications
  • create a standard formulary for pediatric high-risk and commonly used medications
  • standardize concentrations of high-risk medications
  • reduce the number of available concentrations to the smallest possible number
  • implement systems in which weight-based calculations are bypassed during pediatric resuscitations and treatment to reduce potentially harmful mistakes
  • ensure that caregivers are well instructed on medication administration, particularly for pain and antipyretic medications.

EMS Practitioners

3.4 Ensure the use of a pediatric validated tool for weight estimation and documentation in kilograms only.

3.5 Develop dispatch pre-arrival instructions for children and families.

3.6 Ensure family-centered care is integrated into agency policies and procedures


Hospital-based Providers

3.7 Utilize a scale that only weighs—or can be locked—in kilograms only.

3.8 Develop processes for safe medication administration:

● consider adding a pharmacist with pediatric competency to the ED team, especially in large EDs, during times of higher volume

● implement and use computerized physician order entry and clinical decision support with pediatric-specific, kilogram-only dosing rules, including upper dosing limits, within ED information systems

● implement and use computerized physician order entry to create allergy alerts for all prescribed medications

4. Process & Policies

Cross-Cutting Change Strategies

4.1 Develop a process or policy that promotes safe medication administration (see driver 3 for specifics)

4.2 Promote overall patient- and family-centered care which includes:

  • Using lay terms to communicate with patients and families
  • Involving families in patient-care decision making.
  • Having methods for accessing trained-language services to communicate with non-English speaking patients and family members (as opposed to bilingual relatives).
  • Narrating actions and alerting patients and caregivers before interventions are performed.
  • Allowing family members to remain close to their children during resuscitation activities and practice cultural or religious customs as long as they are not interfering with patient care.
  • Allowing family members or guardians to accompany a pediatric patient during transport and/or transfer when appropriate and feasible.

4.3 A process for reported safety or near-miss events which includes a review of the event and identifies opportunities for improvement.

4.4 Develop a policy or standard format to ensure important information and findings are consistently relayed to the provider during all handoffs.

4.5 Ensure pediatric considerations are included in disaster preparedness planning and exercises, including tracking of unaccompanied children and timely reunification with caregivers.

4.6 Ensure pediatric specific screening questions are included in every evaluation including child maltreatment, suicide, and human trafficking.

4.7 Develop protocols for the mode of transport and/or destination of pediatric patients with consideration of regional resources and weighing the risks and benefits of keeping children in their own communities. Consider specific populations such as children and youth with special healthcare needs or those with behavioral health emergencies.


EMS Practitioners

4.8 Ensure there is a policy on the safe transport of children in ambulances.

4.9 Identify online medical direction from a physician with pediatric expertise that can provide support.

4.10 Develop a protocol to address the refusal of medical aid (non-transport decision making and documentation).

4.11 Where possible, consider engaging in mobile integrated health (MIH) and community paramedicine (CP) to provide patient-centered and integrated disease management and social services. A PECC can serve as a pediatric liaison within an EMS MIH/CP system to provide healthcare to children where they live.


Hospital-based Providers

4.12 Work with hospital health information managers on electronic medical record system optimization to recognize out-of-range weights and/or abnormal vital signs.

4.13 Direct families to appropriate resources and review patients’ rights and responsibilities from the perspective of safety.


Templates

  1. The Ask Me to Explain Campaign: A 90-Day Intervention to Promote Patient and Family Involvement in Care in a Pediatric Emergency Department. https://pubmed.ncbi.nlm.nih.gov/27184244/
  2. Pediatric Emergency ABC’s and More (FL EMSC). https://com-jax-emergency-pecsi.sites.medinfo.ufl.edu/wordpress/files/2019/05/PEDReady-ABCs-and-more-ED-poster-with-code-05032019.pdf
  3. Pediatric Emergency Prehospital Reference Guide (WI EMSC). https://www.chawisconsin.org/download/pediatric-emergency-pre-hospital-reference-guide/?wpdmdl=2406&refresh=5cf958b7350001559845047
  4. Pediatric Reference Guide (NE EMSC). https://dhhs.ne.gov/OEHS%20Program%20Documents/EMSC%20Pediatric%20Reference%20Card.pdf
  5. Sample Pediatric Transport Guideline (ME EMSC). https://emscimprovement.center/domains/prehospital-care/prehospital-pediatric-readiness/pprp-toolkit/patient-medication-safety/safe-transport-sample-pediatric-transport-guideline-maine/
  6. Sample Pediatric Transport Guideline (NH EMSC). https://emscimprovement.center/domains/prehospital-care/prehospital-pediatric-readiness/pprp-toolkit/patient-medication-safety/safe-transport-sample-pediatric-transport-guideline-new-hampshire/
  7. Wyoming Responders Safe Transport Initiative (WYRESTRAIN) Strategic Plan
  8. Pediatric Resuscitation and Emergency Medications – Excel Calculator. https://emscimprovement.center/documents/991/Pediatric_Resuscitation_and_Emergency_Medications-Excel_Calculator.xlsx
  9. Quick Reference Code Cards (UCLA Harbor Medical Center). https://emscimprovement.center/documents/682/Quick_Reference_Code_Cards2125_2.zip
  10. Sample Medication Dosing and Intervention Cards (Michigan). https://emscimprovement.center/domains/prehospital-care/prehospital-pediatric-readiness/pprp-toolkit/patient-medication-safety/medication-safety-sample-medication-dosing-and-intervention-cards-michigan/
  11. Sample Pediatric Quick Dosing Reference (Colorado). https://emscimprovement.center/documents/1359/Sample_Pediatric_Quick_Dosing_Reference_Colorado__1.xlsx
  12. FAMILY Survey Tool (English and Spanish). https://emscimprovement.center/domains/prehospital-care/prehospital-pediatric-readiness/pprp-toolkit/patient-family-centered-care/assessments-family-survey-tool/

Tools

  1. Guide for Developing an EMS Agency Safety Program (NAEMT).http://www.naemt.org/docs/default-source/ems-health-and-safety-documents/nemssc/ems-safety-program-guide-10-11-17.pdf?status=Temp&sfvrsn=0.13715842522823762
  2. National Pediatric Readiness Project Toolkit. https://emscimprovement.center/domains/pediatric-readiness-project/readiness-toolkit/
  3. Prehospital Pediatric Readiness Project Toolkit. https://emscimprovement.center/domains/prehospital-care/prehospital-pediatric-readiness/pprp-toolkit/
  4. Patient-and Family-Centered Care Toolkit (EIIC). https://emscimprovement.center/education-and-resources/toolkits/patient-and-family-centered-care-toolkit/
  5. Strategy for a National EMS Culture of Safety. https://www.ems.gov/pdf/Strategy-for-a-National-EMS-Culture-of-Safety-10-03-13.pdf
  6. Pediatric Transportation Webinar (MD EMSC). https://emscimprovement.center/domains/prehospital-care/prehospital-pediatric-readiness/pprp-toolkit/patient-medication-safety/safe-transport-pediatric-transportation-webinar/
  7. Safe Transport of Children by EMS: Interim Guidance (NASEMSO).
  8. Patient- and Family-Centered Care Organizational Self-Assessment Tool. https://emscimprovement.center/domains/prehospital-care/prehospital-pediatric-readiness/pprp-toolkit/patient-family-centered-care/assessment-patient-and-family-centered-care-organizational-self-assessment-tool/
  9. Comfort Positioning During Procedures: https://www.chop.edu/centers-programs/child-life-education-and-creative-arts-therapy/prepare-your-child-visit-doctor/comfort-positioning-during-procedures
  10. Child Life 101 for EDs and Emergency Care Providers: Using Nonpharmacologic Methods to Manage Pain and Anxiety - https://com-jax-emergency-pami.sites.medinfo.ufl.edu/files/2016/08/EMD-01-Child-Life-101-Hendry-et-al_AC_8-10-16.pdf

Further Reading

  1. Agency for Healthcare Research and Quality. Culture of Safety. Patient Safety Primer, 2019. https://psnet.ahrq.gov/primer/culture-safety
  2. Byczkowski, T.L., et al., Family-Centered Pediatric Emergency Care: A framework for Measuring What Parents Want and Value. Acad Pediatr, 2016. 16(4): p. 327-35 https://www.academicpedsjnl.net/article/S1876-2859(15)00278-8/fulltext
  3. Children’s Hospital Association. What Is Patient Safety? 2021; Available from: https://www.hospitalsafetygrade.org/what-is-patient-safety.
  4. Children’s Hospital Association. Track Cognitive Bias to Improve Patient Safety. 2021; Available from: https://www.childrenshospitals.org/Newsroom/Childrens-Hospitals-Today/Articles/2019/11/Track-Cognitive-Bias-to-Improve-Patient-Safety.
  5. Cicero, M.X., et al., Medication Dosing Safety for Pediatric Patients: Recognizing Gaps, Safety Threats, and Best Practices in the Emergency Medical Services Setting. A Position Statement and Resource Document from Naemsp. Prehosp Emerg Care, 2021. 25(2): p. 294-306 https://www.tandfonline.com/doi/abs/10.1080/10903127.2020.1794085?journalCode=ipec20
  6. Cushman, J.T., et al., Ambulance Personnel Perceptions of Near Misses and Adverse Events in Pediatric Patients. Prehosp Emerg Care, 2010. 14(4): p. 477-84 https://www.tandfonline.com/doi/abs/10.3109/10903127.2010.497901?journalCode=ipec20
  7. Emergency Medical Services for Children, N. Family-Centered Prehospital Care: Partnering with Families to Improve Care. n.d., https://www.naemt.org/docs/default-source/education-documents/epc/FamilyCenteredCareTips.pdf?sfvrsn=82de27d7_0
  8. Emergency Nurses Association Position Statement: Weighing All Patients in Kilograms. 2020. https://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/weighingallpatientsinkilograms.pdf?sfvrsn=9c0709e_6
  9. Escobar, M.A., Jr. and C.J. Morris, Using a Multidisciplinary and Evidence-Based Approach to Decrease Undertriage and Overtriage of Pediatric Trauma Patients. J Pediatr Surg, 2016. 51(9): p. 1518-25 https://www.jpedsurg.org/article/S0022-3468(16)30021-5/fulltext
  10. Garra, G., et al., Validation of the Wong-Baker Faces Pain Rating Scale in Pediatric Emergency Department Patients. Acad Emerg Med, 2010. 17(1): p. 50-4 https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2009.00620.x
  11. Merkel, S., et al., The Flacc: A Behavioral Scale for Scoring Postoperative Pain in Young Children. Pediatric nursing, 1996. 23: p. 293-7 https://www.researchgate.net/publication/13998379_The_FLACC_A_Behavioral_Scale_for_Scoring_Postoperative_Pain_in_Young_Children
  12. Mueller, B.U., D.R. Neuspiel, and E.R.S. Fisher, Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care. Pediatrics, 2019. 143(2) https://pediatrics.aappublications.org/content/127/6/1199
  13. R.C., A., et al., eds. Pediatric Care Coordination: An Interprofessional Resource to Effectively Engage Patients and Families in Achieving Optimal Child Health Outcomes. 2nd ed. 2019, Boston Children's Hospital https://medicalhomeinfo.aap.org/tools-resources/Documents/PCCC%202nd%20Edition/Full%20Pediatric%20Care%20Coordination%20Curriculum.pdf.
  14. Seiger, N., et al., Validity of Different Pediatric Early Warning Scores in the Emergency Department. Pediatrics, 2013. 132(4): p. e841-50 https://pediatrics.aappublications.org/content/132/4/e841
  15. The Joint Commission Human Factors Analysis in Patient Safety Systems. The Source, April, 2015. 13, https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/assetmanager/humanfactorsthe_sourcepdf.pdf?db=web&hash=085A09275C38FACB50BC3D92CB35450A
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Questions?

Meredith Rodriguez, PhD, CCRC

pwdc@emscimprovement.center