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Pensar Enfermagem / v.28 n.01 / February 2024
DOI: 10.56732/pensarenf.v28i1.298
Review Article
How to cite this article: de Sousa MST, Correia MJPL, Nunes EMGT. Family perception of safety in
hospital care for the pediatric patient: scoping review. Pensar Enf [Internet]. 2024 Feb; 28(1): 14-25. Available
from: https://doi.org/10.56732/pensarenf.v28i1.298
Family perception of safety in hospital care for the
pediatric patient: scoping review
Abstract
Introduction
Patient safety is one of the fundamental pillars of the quality of healthcare. The perception
of families of hospitalized children allows for an expanded understanding of the factors
contributing to the occurrence of safety incidents, raising awareness among healthcare
professionals and organizations for implementing safer practices.
Objective
To map the available scientific evidence regarding the family's perception of the safety of
care provided to hospitalized children.
Methods
A scoping review was conducted following the Joanna Briggs Institute recommendations
(2020), adhering to the PRISMA-ScR checklist. Searches were performed on the CINAHL
and MEDLINE databases (via EBSCOhost), SciELO, Scopus, and RCAAP, using
descriptors and free terms in Portuguese, English, Spanish, and French, from 1999 onwards.
Two independent reviewers carried out the search, study relevance analysis, data extraction,
and synthesis between March and May 2022.
Results
Out of the 1,590 studies obtained, 29 were included as they met the eligibility criteria and
addressed the objectives of the scoping review. Families reported various safety incidents,
with a higher prevalence related to therapeutic administration. They frequently cited lack
of communication as a contributing factor to unsafe care. Family members provided
diverse suggestions for promoting safety, emphasizing increased vigilance, attention, and
information transmission.
Conclusion
Family members of hospitalized children can identify safety incidents and contributing
factors to unsafe care, offering suggestions for improvement. Understanding family
members' perceptions and involving them are essential for enhancing the safety of
hospitalized children. This scoping review allows healthcare professionals to reconsider their
practices and recognize the importance of family involvement in care.
Keywords
Family; Hospitalization; Patient safety; Pediatrics.
Mariana Serpa Teixeira de Sousa1
orcid.org/0009-0002-2580-4980
Maria João Pereira Lopes Correia2
orcid.org/0009-0008-6596-8342
Elisabete Maria Garcia Teles Nunes3
orcid.org/0000-0001-7598-0670
1 Master's degree with a specialization in Child Health
and Pediatrics Nursing, Portuguese Catholic
University, Lisbon, Portugal.
2 Master's degree with a specialization in Child Health
and Pediatrics Nursing, Portuguese Catholic
University, Lisbon, Portugal.
3 PhD. Nursing School of Lisbon (ESEL), Lisbon.
Nursing Research, Innovation and Development
Centre of Lisbon (CIDNUR), Lisbon, Portugal.
Corresponding Author:
Mariana Serpa Teixeira de Sousa
Email: mariana94_@hotmail.com
Received: 18.10.2023
Accepted: 20.12.2023
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Introduction
Safety is a fundamental dimension of healthcare quality.
According to the World Health Organization (WHO),
high-quality care involves being safe, effective,
person-centered, timely, efficient, equitable, and
integrated.¹ The recognition of the importance of patient
safety and the growing awareness on the topic have
primarily emerged in the last two decades, following the
release of the 1999 Institute of Medicine report "To Err Is
Human," which revealed the immense scope of preventable
adverse events at that time.2 Currently, it is acknowledged
that healthcare delivery involves risks, and despite all
efforts to prevent failures, much remains to be done to
ensure that all patients receive care with the utmost safety.3
Patient safety, as defined by the WHO, is the reduction of
the risk of unnecessary harm associated with healthcare to
an acceptable minimum.4 Since then, this definition has
been systematically used in the literature to the present day.
In Portugal, the right to health protection is established as
a patient's right according to the Health Basic Law,
approved by Law No. 95/2019, dated September 4, with
safety being one of its essential components.5 Similarly,
according to the Universal Declaration of Human Rights,
in Article 3, "everyone has the right to life, liberty, and
security of person."6(p489) The continuous pursuit of
patient safety is thus a universal ethical and legal obligation
for all healthcare professionals and organizations.3
Despite limited studies on the safety of pediatric patients,
the data is unsettling. It is believed that children, due to
their specificity, are more vulnerable to adverse events
during hospitalization compared to the adult population.7
Their specificity includes accelerated metabolism, greater
variation in body weight, requiring frequent adjustment of
medication doses and concentrations, organ and system
development immaturity, curiosity, and unpredictability of
movements, all characteristics of a child's development,
requiring increased monitoring and constant vigilance.8
The child's family serves as the primary reference during
their developmental process, understanding their
specificities, and acting as important partners in ensuring
their physical and emotional safety.9 Children are often
unable to contribute to controlling their own safety, making
the effective participation of the caregiver crucial to serving
as a prevention barrier to adverse events.10 The caregiving
family member is typically recognized as the child's main
caregiver, accompanying them during hospitalization,
helping them adapt, and promoting their safety.11
It is understood that patients and their families can identify
incidents and adverse events not detected by professionals
and report them without constraints or biases, providing
new and valuable information about the type and frequency
of these occurrences. Through family members, it is
possible to have a distinct perspective on hospital care
safety often not reported in notification systems.12
The perception of family members can be used as a quality
outcome indicator to measure the performance of service
delivery and its evaluation, signaling the existence of
failures in care and organizational systems, and contributing
to the planning of new and safer strategies and practices.13
In the fourth of the seven strategic objectives of the Global
Patient Safety Action Plan 2021-2030, which aims to
eliminate preventable harm, it is mentioned: involve and
empower patients and families to help support the journey
toward safer healthcare. This objective reinforces that
patient and family involvement should be an integral part
of their safety promotion so that their voice and experience
result in a beneficial and powerful influence on clinical
practice and global and national policies.14
It becomes indispensable for healthcare institutions to
encourage the exchange of knowledge among patients,
caregivers, family members, and professionals to increase
patient safety, with care being built from the partnership of
all involved.15 Although their participation is encouraged, it
is reported that it may still be hindered by healthcare
professionals' fear of the "transfer" of competencies from
professionals to parents/family.16
There is diverse and scattered literature available on the
perception of family members/parents/caregivers about
the safety of care provided to hospitalized children, mostly
primary studies, supporting the need for this review. A
preliminary search in Prospero National Institute for
Health, JBI Evidence Synthesis, OSF home, and the
Cochrane Database of Systematic Reviews found no review
protocols or current systematic reviews on the posed
question, leading to the need to map scientific evidence in
this area.
The perception of family members of hospitalized children
regarding the safety of care, including factors contributing
to unsafe care and their suggestions for improvement,
constitutes an added value to raise awareness among
healthcare professionals and organizations, fostering
learning and the adaptation of behaviors that promote
greater safety.
Objectives
The objective of this review is to map, in scientific
evidence, the family's perception of the safety of care
provided to hospitalized children.
The current review aims to address the following question:
“What is the family's perception of the safety of care
provided to hospitalized children?” Starting from the main
question, we also intend to identify: “What safety incidents
are identified by family members of hospitalized children?”;
“What factors contribute to unsafe care identified by family
members of hospitalized children?”; “What suggestions are
mentioned by family members to promote the safety of
care provided to hospitalized children?”.
Methods
The scoping review was conducted following the JBI
methodology (2020) for scoping reviews, and the data are
presented according to the Preferred Reporting Items for
Systematic Reviews and Meta-analyses for Scoping Reviews
(PRISMA-ScR) checklist recommendations.17 A review
16 | Sousa, M.
Review Article
protocol was created and registered on the platform Open
Science Framework (OSF) (https://osf.io/mz5e9).
Eligibility Criteria
For the definition of inclusion criteria, the mnemonic
"PCC" was used following the JBI recommendations for
scoping reviews. This represents the terms “population”,
“concept”, and “context”.18
Inclusion criteria for the study:
• Population: The current review considers studies that
include parents/family members/companions/caregi
vers of hospitalized children, regardless of the child's
age (0-18 years) and the cause of hospitalization.
No sex, age, ethnicity, or other personal characteristics
restrictions were applied.
• Concept: Studies focused on patient safety were
included. Patient safety is defined as the reduction of
the risk of unnecessary harm related to healthcare to
an acceptable minimum.4 Included were studies that
addressed any factors identified by family members
related to the safety of hospitalized children, including
contributors to unsafe care and suggestions for
improvement to promote safety. Studies that included
questions related to safety culture that addressed the
review's questions were also included.
• Context: The review covers all contexts of providing
hospital care to children (0-18 years), including
emergency services, various specialty admissions,
operating rooms, intensive care, and neonatology. No
cultural or geographical restrictions were imposed.
Quantitative, qualitative, and mixed-methods studies,
literature reviews, and grey literature, among others, were
considered relevant to the review question and were
included if written in Portuguese, English, Spanish,
or French.
Exclusion Criteria for the Study:
As exclusion criteria, opinion articles, advertisements,
editorials, or letters to the editor were defined.
Given that a scoping review aims to map all available
evidence,18 no temporal limit regarding the publication date
of sources was established. However, taking into account a
significant evolution in the safety culture of healthcare
organizations since the release of the Institute of Medicine's
“To Err Is Human” report in 1999,2 It was considered that
earlier studies might not align with the current reality of the
safety culture. Therefore, only studies published after 1999
were included.
Search Strategy
The research strategy aimed to obtain published and
unpublished studies that met the defined inclusion criteria
and addressed the scoping review's questions.
Firstly, the MEDLINE (via EBSCOhost) and CINAHL
(via EBSCOhost) databases were accessed for an
exploratory search of relevant studies and identification of
the most frequent words in titles and abstracts. The second
step involved identifying indexing terms and free terms,
applying Boolean operators AND and OR electronically in
the MEDLINE (via EBSCOhost), CINAHL (via
EBSCOhost), SciELO, and Scopus databases. The search
equation was adapted for each database, as specified in
Table 1. Additionally, grey literature was searched by
consulting the Portuguese Open Access Scientific
Repository (RCAAP). The third step included checking the
reference lists of selected studies after full-text reading to
find potential complementary relevant studies to address
the research questions.
Two reviewers searched collaboratively during the months
of March and April 2022.
Table 1. Search Strategy
Search Strategy
( MH ( (Parents OR Caregivers OR Family OR "Parental Attitudes" OR "Caregiver Attitudes" OR "Family Attitudes") ) OR TX (
(“Parents Perceptions” OR “Parents reports” OR “Caregivers perceptions” OR ”Caregivers reports” OR “Family perceptions” OR
“Family reports”) ) ) AND ( MH ( ("Patient Safety" OR "Child Safety" OR "Risk Assessment" OR "Risk Management" OR "Attitude
to Risk" OR "Quality of Health Care") ) OR TX ( (“Patient Harm” OR “Medical Errors“) ) ) AND ( MH ( ("Pediatric Units” OR
“Pediatric Care” OR "Hospitals, Pediatric" OR "Infant, Hospitalized" OR "Child, Hospitalized" OR "Adolescent, Hospitalized" OR
"Pediatric nursing") ) OR TX ( (“Pediatric Hospitalization” OR “Pediatric Urgent Care” OR “Pediatric Operating room” OR
“Pediatric Intensive Care” OR “Neonatology” OR “Hospitalized Children”) ) )
( MH ( (Parents OR Caregivers OR Family) ) OR TX ( (“Parents Perceptions” OR “Parents reports” OR “Caregivers perceptions”
OR ”Caregivers reports” OR “Family perceptions” OR “Family reports”) ) ) AND ( MH ( (“Patient Safety” OR “Safety
Management” OR “Risk Management” OR “Patient Harm” OR “Medical Errors” OR “Patient Reported Outcome Measures” OR
“Quality of Health Care”) ) OR TX ( (“Child Safety” OR “Adverse Event” OR “Incident Reports”) ) ) AND ( MH ( (“Hospitals,
Pediatric” OR “Intensive Care Units, Pediatric” OR “Child, Hospitalized” OR “Adolescent, Hospitalized” OR “Hospital Units” OR
“Pediatric Nursing” OR Pediatrics) ) OR TX ( (“Pediatric Hospitalization” OR “Pediatric Urgent Care” OR “Pediatric Operating
room” OR “Pediatric Intensive Care” OR “Pediatric Care” OR “Hospitalized Children”) ) )
((parents OR caregivers OR family OR "Parents perceptions" OR "family perceptions" OR "caregivers perceptions")) AND
(("patient safety" OR "safety management" OR "risk management" OR "risk assessment" OR "incident reports" OR "child safety"))
AND (("Pediatric Hospital" OR "Hospitalized infant" OR "Hospitalized child" OR "Hospitalized children" OR "Hospitalized
adolescent" OR "Pediatric Intensive Care" OR "pediatric operating room" OR neonatology))
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( TITLE-ABS-KEY ( ( parents OR caregivers OR family OR "Parents perceptions" OR "family perceptions" OR "caregivers
perceptions" ) ) AND TITLE-ABS-KEY ( ( "patient safety" OR "safety management" OR "risk management" OR "risk
assessment" OR "incident reports" OR "child safety" ) ) AND TITLE-ABS-KEY ( ( "Pediatric Hospital" OR "Hospitalized
infant" OR "Hospitalized child" OR "Hospitalized children" OR "Hospitalized adolescent" OR "Pediatric Intensive Care" OR
"pediatric operating room" OR neonatology ) ) ) AND ( LIMIT TO ( LANGUAGE , "English" ) OR LIMIT-TO (
LANGUAGE , "Portuguese" ) OR LIMIT-TO ( LANGUAGE , "French" ) OR LIMIT-TO ( LANGUAGE , "Spanish" ) )
AND ( LIMIT-TO ( PUBYEAR , 1999 ) OR LIMIT-TO ( PUBYEAR , 2022 )
(parents OR caregivers OR family OR "Parents perceptions" OR "caregivers perceptions" OR "family perceptions") AND ("patient
safety” OR "safety management" OR "risk management" OR "risk assessment" OR "incident reports" OR "child safety") AND
("Pediatric Hospital" OR "Hospitalized infant" OR "Hospitalized child" OR "Hospitalized children" OR "Hospitalized adolescent"
OR "Pediatric Intensive Care" OR "pediatric operating room" OR neonatology)
Study Selection
All studies obtained through the search strategy were
exported to Zotero software (6.0.6/2022), where duplicates
were removed, and a screening of studies was conducted by
critically reading their titles and abstracts by two
independent reviewers.
Potentially relevant studies were imported into Rayyan
QCRI®, where they proceeded to the full-text reading
phase, also carried out by two independent reviewers. Each
study was analyzed in detail regarding the inclusion criteria.
As a scoping review, aiming to map the available knowledge
on the topic, critical evaluation of sources was waived. Two
studies were identified without a freely available full
version, and the publishing journal was contacted to
request the studies, but there was no response.
During the study selection process, forty-seven
disagreements arose between the two reviewers, which
were resolved through consensus between the parties,
without the need to consult additional reviewers.
Data Extraction and Synthesis
For the extraction of data from the included studies, the
JBI-proposed data extraction tool was used, which was
adapted to the review's objectives. The extracted data from
the studies included specific details about authors, title,
year, country, objectives, study type, participants, context,
and key results relevant to the review questions.
Two independent reviewers performed data extraction.
Twenty-two disagreements arose, which were resolved
through consensus between the parties, with the need to
involve two additional reviewers in two of these cases. Two
reviewers conducted the synthesis and presentation of the
data jointly.
Results
The database search yielded 1,590 studies. Out of these, 155
studies were automatically identified as duplicates and were
removed, leaving 1,435 studies. After reading titles and
abstracts, 1,290 studies were excluded, and an additional 9
were manually identified as duplicates, resulting in 136
studies. After a full-text reading in line with the inclusion
criteria, 110 studies were excluded, leaving 26 studies
included. Three more studies were selected from the
reference lists of the included studies, totaling 29 studies
included for review. Figure 1 presents the flowchart of the
study selection process following PRISMA-ScR
guidelines.17
18 | Sousa, M.
Review Article
Figure 1. Flowchart of the study selection process (adapted from Tricco et al., 2018)17
Characteristics of Included Studies
The studies span the time frame from 1999 to 2020, with
the highest publication year being 2019 (21%).15,19,20,21,22,23
There is a predominance of studies published in the United
States of America (USA) (45%)20,24,25,26,27,28,29,30,31,32,33,34,35
and Brazil (34%).9,15,19,36,37,38,39,40,41,42
The majority of studies (86%) adopt a qualitative
approach.9,15,19,20,22,23,25,26,27,28,29,30,32,33,34,35,36,37,38,39,40,41,42,43,44
In total, this review includes 4,872 participants, of which
3,722 (76%) are parents,20,21,22,24,25,26,27,28,29,30,31,32,33,34,35,37,43
883 (18%) are family members,9,19,36,38,39,41,44,45 227 (5%) are
caregivers,15,23,42 and 40 (1%) are companions.40
Some studies additionally address the perceptions of
individuals other than family members (17%); however,
their inclusion was possible by extracting data only from
the population under study.19,20,21,36,43
Synthesis of Results
The characteristics of the studies included in the scoping
review and the synthesis of the main results of interest
related to the research questions are presented in Table 1.
IDENTIFICATION
SELECTION
INCLUSION
Studies identified in the databases (n = 1,590)
CINAHL (via EBSCOhost) = 633
MEDLINE (via EBSCOhost) = 390
SciELO = 22
Scopus = 538
RCAAP = 7
Studies after duplicate removal
(n= 1,435)
Studies excluded for duplicates
(n= 155)
Studies excluded after reading titles and abstracts
(n=1,290)
Manually identified duplicates excluded
(n= 9)
Full-text studies for thorough reading
(n=136)
Studies excluded based on inclusion and exclusion
criteria (n=110)
Studies selected
(n=26)
Studies included after reading the references
(n=3)
Studies included in the scoping review
(n=29)
ELIGIBILITY
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Chart 1. Characteristics of Included Studies
Authors
Year
Country
Type of Study
Participants
Context
Objective
Main Results
Franco et al.9
2020
Brazil
Qualitative Study
18 family members
Pediatric Unit at the
University Hospital of
São Paulo
To understand the meaning
attributed by family members to
the safety of pediatric patients,
paying attention to the
possibilities of their
collaboration.
Family members recognized risks for errors and harm in care. They
identified themselves as support elements in minimizing incidents,
valuing a child and family-centered approach, and considering care
partnership as opportunities to promote safety.
Hoffmann et al.15
2019
Brazil
Qualitative Study
40 caregivers
3 Hospital Units in
Porto Alegre
To analyze security incidents
identified by caregivers of
hospitalized children.
Caregivers reported incidents related to falls, feeding,
patient/caregiver identification, medication, hand hygiene, hospital
environment, nosocomial infections, and procedure performance.
Communication and the relationship between caregivers and
professionals were the main factors reported for safety incidents.
Biasibetti et al.19
2019
Brazil
Qualitative Study
94 family members
Pediatric Inpatient
Units in 3 hospitals in
Porto Alegre
To analyze the perception of
professionals and family
members regarding
communication for the safety of
pediatric inpatient care.
Most caregivers understand that being informed about medications
and procedures performed allows for a closer look, increasing the
child's safety. They mentioned that communication with
professionals allows them to be guided on the best way to
participate in care, avoiding risks to the child's health.
Wei et al.20
2019
USA
Qualitative Study
13 parents
Children's Hospital in
the USA
To understand the perception of
parents and healthcare
professionals about the quality of
care.
Parents reported feeling secure when observing how professionals
treated their children with “compassion and expertise”. They noted
an increased sense of security and protection when nurses who were
not assigned to care for their children examined them and showed
interest in their questions.
Witanowska et
al.21
2019
Poland
Mixed Study
110 parents
Pediatric Wards in
hospitals
To clarify if the hospitalization
process is a difficult situation for
the child in the opinion of their
parents and medical team.
Out of parents, 92% considered nurses to have a high level of skills.
In total, 57.9% believed that nurses ensure not only physical but
also psychological safety. They mentioned that a good relationship
between the team and family favors the exchange of information,
which can influence attitude change and safety promotion.
Shala et al.22
2019
Australia
Qualitative Study
23 parents
Pediatric Hospital in
Sydney
To explore parents' knowledge
and awareness of falls in
hospitalized children.
Over 50% of parents were unaware of the occurrence of falls during
hospitalization but expressed concern. Some, from experience,
adopted more prevention strategies. They mentioned not receiving
education about falls and being unaware of risk assessment. They
believed that their presence and supervision reduced the risk
of falling.
Massa et al.23
2019
Colombia
Qualitative Study
163 caregivers
Pediatric Hospital in
Cartagena
To identify caregivers'
perception of safety conditions
in pediatric hospital care.
Caregivers reported feeling secure in the care provided due to trust
in professionals. They identified phlebitis and drug reactions as the
most common incidents and falls, infections, and pressure ulcers as
less common.
Cox et al.24
2013
USA
Mixed Study
172 parents
3 University Pediatric
Hospital units
To understand parents'
perceptions of the hospital safety
environment through the AHRQ
tool.
In general, parents considered the institution's safety environment
positive, with communication availability being the most mentioned
aspect. However, 39% of parents agreed or strongly agreed that they
needed to ensure care to avoid errors.
Schaffer et al.25
2000
USA
Qualitative Study
1,405 parents
Children's Hospital
units
To understand parents'
satisfaction with communication,
safety, and the physical
environment to identify
opportunities for performance
improvement.
Parents expressed fears and identified professional behaviors that
made them feel secure. Main fears included contracting infections
and child abduction. They would like nurses to observe their
children more frequently and emphasized the importance of open
communication.
Harbaugh et al.26
2004
USA
Qualitative Study
19 parents
Intensive Care Unit in
the Midwest
To understand parents'
perceptions of nurses' caregiving
behaviors.
Parents reported feeling more secure with constant monitoring by
nurses when associated with effective communication and
information provided appropriately. When nurses' behavior was
perceived as careless and non-protective, the Pediatric Intensive
Care Unit (PICU) environment was identified as unsafe.
Rosenberg et
al.27
2016
USA
Qualitative Study
12 parents
Urban Hospital Ward
To describe families'
perspectives on the safety of
their hospitalized children.
In addition to reducing harm, parents considered that safety
involves comfort. They observed safety-promoting behaviors and
identified communication and environmental conditions failures.
They mentioned that their relationship with professionals affects
care. They emphasized the importance of effective communication
and suggested fixing safety recommendations.
Stubblefield &
Murray28
1999
USA
Qualitative Study
15 parents
Children's Hospital in
the Midwest
To determine how parents of
lung transplant recipients
experience and respond to
relationships with healthcare
professionals.
Parents reported feeling safer when professionals showed concern
for their children, emphasized the value of continuity of care, and
described a sense of abandonment when their children's condition
worsened, noting the need for more attention from professionals.
Sobo29
2005
USA
Qualitative Study
35 parents
Children's Hospital in
San Diego
To understand the safety
concerns of parents of pediatric
patients undergoing surgery.
Parents considered care safe. Concerns were related to anesthesia,
complications, and vulnerability due to physical immaturity. They
did not consider the team guilty of complications. Reassuring
factors reported: being a low-risk surgery, previous experiences,
20 | Sousa, M.
Review Article
Authors
Year
Country
Type of Study
Participants
Context
Objective
Main Results
trust in the team, clarification opportunities, and identity
verification.
Tarini et al.30
2009
USA
Qualitative Study
278 parents
Children's Hospital
To determine the percentage of
parents concerned about medical
errors and their relationship with
medical interactions.
63% of parents reported the need to monitor the hospital care of
their children to ensure that no errors are committed. Parents with
less proficiency in English and less confidence in interacting with
professionals were more likely to report the need to care for and
supervise their children's care.
Khan et al.31
2017
USA
Prospective Cohort
Study
717 parents
4 Pediatric Hospital
Units
To compare medical errors and
adverse events (AEs) identified
by family members with
incidents reported by the
hospital.
Parents reported concerns, of which 51.8% were classified as real
safety concerns; 40%, non-safety-related quality concerns; and 8.2%,
other concerns. Identified AEs included multiple needle sticks,
treatment delays, incorrect doses, and adverse effects of
medications.
Khan et al.32
2016
USA
Qualitative Study
471 parents
Pediatric Hospital in
Boston
To determine how frequently
parents experience safety
incidents and the proportion that
corresponds to AE definitions.
Of parents, 8.9% reported safety incidents. Of these, 62.2% were
classified as real safety incidents by the authors. The most reported
harmful errors were related to procedures or diagnosis, while non-
harmful errors/near-misses seemed more related to medication.
Sobo et al.33
2002
USA
Qualitative Study
20 parents Pediatric
Oncology Unit
To identify system weaknesses
and develop strategies to prevent
future errors regarding
medication administration.
Parents reported medication administration and communication
failures as major safety concerns. They recognized that errors can
occur because of the involvement of many professionals. They
would like nurses to inform them of the names of medications,
standardization of procedures, and equality in information provided
to parents.
Mazor et al.34
2010
USA
Qualitative Study
35 parents Children's
Hospital
To explore parents' perceptions
related to events they believed to
be medical errors in their
children's care.
The most cited cause of medical errors was lack of professional
rigor, followed by lack of knowledge, skills, experience, or
competencies, insufficient time with the patient, and lack of
communication. They mentioned some professionals dismissed
their concerns and did not seek advice from colleagues.
Lyndon et al.35
2014
USA
Qualitative Study
46 parents
NICU in an Academic
Hospital
To describe how parents
understand child safety and their
safety concerns.
Parents expressed confidence in the team and feelings of safety in
care. They viewed safety as a combination of three dimensions:
physical (safe practices), developmental (interaction, growth, and
bonding), and emotional (trust in professionals, information
provision, and care involvement). They identified the quality and
consistency of care as fundamental. They expressed concern about
the ability of some professionals and not "knowing the baby."
Wegner &
Pedro36
2012
Brazil
Qualitative Study
15 family members
Pediatric units in a
University Hospital in
Porto Alegre
To analyze how family
members/accompaniers and
healthcare professionals
understand adverse events in
care situations.
Family members considered the hospital safe despite identifying
failures in medication, communication, deterioration of health after
procedures, infection risk, inadequate professional ratio, and care
provision they considered the responsibility of professionals. They
mentioned strategies: use of technologies, effective communication,
teamwork, individualized care, handwashing, equipment
sterilization, and care guidance and supervision.
Moura et al.37
2020
Brazil
Qualitative Study
18 parents
Neonatal Unit at a
Hospital in the South
To understand parents'
experience as a strategy to assess
the quality of nursing care.
Parents identified 43 critical incidents. They reported weaknesses in
medication administration, equipment use, improper positioning of
babies, heating after bathing, skincare, and incorrect hand hygiene.
Hoffmann et al.38
2020
Brazil
Exploratory-
Descriptive Qualitative
Study
91 family members
3 Hospitals in Porto
Alegre
To understand the main safety
incidents reported by family
members of patients admitted to
pediatric units.
Family members identified incidents related to medication, hand
hygiene, use of personal protective equipment (PPE), diet supply,
falls, communication, patient identification and monitoring,
procedures, and visit control. They emphasized the team's reflection
on their role in transmitting information and guidance to families.
Rodrigues et al.39
2018
Brazil
Qualitative Study
23 family members
Neonatal Unit at a
Hospital in the South
To analyze how parents identify
patient safety in the neonatal
unit.
Family members reported concerns about unit access control,
infection risk, and communication. They felt secure, considering
strategies for safety: visit restriction, effective communication,
empathetic care, infection control, fall risk assessment, patient
identification, and measures for correct prescription/administration
of medications.
Lima et al.40
2017
Brazil
Qualitative Study
40 companions
Pediatric Unit at a
university hospital in
Goiás
To understand the companion of
the hospitalized child's opinion
regarding the quality and safety
of nursing care.
Parents reported failures in patient identification, hand hygiene,
medication administration, fall and skin injury prevention. They
reported concerns about care integrity, professional skills,
medication administration, infection control, and the presence of
strangers in the unit. They emphasized personal and relational
aspects of safe care: attention, technical ability, patience, affection,
communication skills, education, and respect.
Silva et al.41
2012
Brazil
Qualitative Study
13 family members
PICU at the Pediatric
Hospital in Porto
Alegre
To describe adverse events
identified by the family/caregiver
in a Pediatric Intensive Care
Unit.
Family members reported poor care provision, lack of scientific
knowledge, and lack of information provided. They reported feeling
insecure when excluded from treatment. As promoters of safety,
they considered caring with affection and the use of technology.
They suggested strategies: more qualified professionals, advanced
technology use, and guidance tailored to family needs.
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DOI: 10.56732/pensarenf.v28i1.298
Review Article
Authors
Year
Country
Type of Study
Participants
Context
Objective
Main Results
Peres et al.42
2018
Brazil
Qualitative Study
24 caregivers
3 Pediatric Inpatient
Services at a University
Hospital in the South
To understand the perception of
family members and caregivers
regarding Patient Safety in
Pediatric Inpatient Units.
Parents have limited knowledge about the concept of safety. They
did not consider it an error when it does not result in harm. Failures
in medication, communication, patient identification, and infection
control were identified. Exclusion from care or perceived ineffective
communication made them feel insecure. They considered their
presence essential for safe care. Suggestions included increasing
professional qualification and providing information to families.
Bruyneel et al.43
2017
Belgium
Qualitative Study
333 parents
University Hospitals in
Leuven
To test the Child HCAHPS
(survey on family inpatient
experiences) in Belgium to
instigate international
comparison.
Over 50% of parents responded negatively about implementing
strategies for error prevention and reporting their concerns. In total,
84.6% reported that child identification was performed before
medication administration. Only 10.9% were informed of how to
report errors.
Lachman et al.44
2015
England
Qualitative Study
85 family members
Great Ormond Street
Children's Hospital
To test a tool for reporting
incidents by patients and family
members to sensitize the team to
improve safety.
The highest number of safety concerns was about communication
failures, followed by significant delays in hospitalization and care
provision, as well as problems related to cleanliness and hygiene.
Parents reported feelings of vulnerability when their children are
hospitalized.
Daniels et al.45
2012
Canada
Mixed Study
544 family members
1 Ward at BC
Children's Hospital
To identify the results of
implementing a system for
notifying adverse events to
family members of children
admitted to a surgical service.
Of the adverse events identified by families, the study’s authors
considered only 48% legitimate patient safety concerns. Out of the
families, 66% believed that professionals were aware of the reported
concerns. Lack of communication was the most identified problem
as an enhancer of adverse events.
Discussion
Based on the main results of interest from the included
studies, a narrative synthesis was conducted to address the
scoping review questions.
What is the family's perception of the safety of care
provided to hospitalized children?
In eight studies (28%), family members shared the same
perception that, although they identified safety concerns,
they considered the care provided to hospitalized children
to be safe.20,23,24,25,29,35,36,39
Trust in healthcare professionals was reported,23,35 and
some family members perceived a high level of competence
in professionals, ensuring not only physical but also
psychological safety.21
On the other hand, fears and safety flaws were expressed
in six studies (21%).20,24,26,29,35,36 They reported poor care,
limited scientific knowledge, and a lack of information
provided by professionals.41 Some responded negatively
regarding the implementation of strategies for error
prevention and guidance on reporting their concerns.43
Feelings of vulnerability when children are admitted to the
hospital were reported.44
Family members mentioned feeling more secure with
constant nurse surveillance when associated with adequate
communication and information provision.24,26
In 10% of the studies, there is an emphasis on the personal
and relational aspects of healthcare professionals, identified
as contributing factors to a greater sense of security:
attention, patience, affection, communication skills,
education, respect, and care with "compassion and
expertise" for families and children.20,25,41 A greater sense
of security was reported when professionals demonstrated
care for children,20,28 showed interest in their questions, and
observed children, even those not under their care.20
Some family members perceived safety as a combination of
different dimensions: physical, through safe practices;
emotional, through trust in healthcare professionals,
information provision, and engagement in care; and child
development, through interaction, growth, and bonding.35
Family members also understood safety from a perspective
that involved comfort.27
They considered that their relationship with professionals
affected care27 and mentioned that a good relationship
between the team and family members facilitates the
exchange of information, potentially influencing attitudes
and promoting safety.21
Five studies (17%) reported how family members
considered their presence essential to promote safe care
and ensure that errors are not committed.9,22,24,30,42
Regarding this aspect, family members with limited
language proficiency and less confidence in interacting with
professionals were more likely to report the need to care
for and supervise care.30
One study specifically addresses the topic of falls. It states
that most family members were unaware of falls during
hospitalization but expressed concern. Moreover, the fact
that they had already gone through this experience resulted
in increased vigilance and the adoption of prevention
strategies.22
In a study conducted in a surgical context, family members
stated they did not consider the healthcare professional
team guilty of potential complications. Instead, they
attributed the possibility of occurrence to the inherent
immaturity of the child's physical characteristics and the
unpredictability of the child.29 In another study, it was also
possible to understand that, for some family members, the
occurrence of an incident may not be seen as a safety error
if it does not result in harm.42
In three studies (10%), some safety concerns reported do
not fall under real safety concerns but rather as other
non-safety-related quality concerns.31,32,45
22 | Sousa, M.
Review Article
What are the safety incidents identified by family
members of hospitalized children?
In decreasing order of reports frequency, the following
safety incidents were identified: those related to medication
administration (24% of the studies)15,23,31,32,38,40,42, patient
identification, hospital infection control through hand
hygiene, and the use of Personal Protective Equipment
(PPE) (14%)15,38,40,42, falls (14%)15,23,38,40, procedure
performance (10%)15,32,38, communication (10%)15,38,42, diet
supply (7%)15,38, phlebitis, and skin injuries (7%)23,40,
multiple needle pricks (3%)31, diagnosis (3%)32, delays in
treatment (3%)31, and child surveillance and visit
control (3%).38
What are the factors contributing to unsafe care
identified by family members of hospitalized children?
The factors contributing to unsafe care identified by family
members of hospitalized children were grouped into two
categories: factors related to professionals and factors
related to the organization.
Regarding the former, the majority of family members of
hospitalized children identify communication failures
among the professionals and between the team and the
family as one of the contributing factors to unsafe care,
with this being the most reported main cause in the
included studies (31%)15,33,34,36,39,41,42,44,45.
They expressed feeling insecure when excluded from
care41,42 and when nurses' behavior was perceived as
careless and non-protective28. Concerns were raised about
the lack of knowledge, skills, experience, or competencies
of some professionals34,40, lack of professional rigor, and
insufficient time spent with the child34. Concerns were also
described for not "knowing the baby"35. They mentioned
some professionals dismissed their concerns and did not
seek advice from colleagues34. They reported providing
care that they believed was the responsibility of
professionals36. They recognized, in turn, that errors can
occur because of the involvement of many professionals33.
Weaknesses were also mentioned regarding medication
administration33,36,37,40, use of equipment, baby positioning,
warming after bathing, skincare, and hand hygiene as
contributing factors to unsafe care37. Some family members
reported feeling abandoned when the children's condition
worsened28. They mentioned not receiving education about
falls and being unaware of risk assessment22.
As for factors contributing to unsafe care related to
organizations, family members reported significant delays
in hospitalization, in care provision44, and an inadequate
ratio of professionals36. They reported concerns about
controlling strangers' access to units39,40 and the cleanliness
and hygiene conditions of the units due to the risk of
infection.36,39,40,44
What are the suggestions mentioned by the family
members to promote the safety of care provided to
hospitalized children?
Suggestions for improvement to promote safety were also
grouped into two categories: those directed toward
healthcare professionals and those directed toward the
organization.
Regarding the former, family members suggested
professionals observe hospitalized children more
frequently,26 and reinforced the need for greater attention
from healthcare professionals28 and the importance of
open communication.25,36,38
They valued and encouraged a child and family-centered
approach, considering the partnership of care as an
opportunity to promote safety.9
Still regarding communication, the majority of companions
understood that being informed about the medications and
procedures performed allows a closer look, increasing the
child's safety.19 They would like to be informed of the
names of medications, not just the types of medications,
that all professionals perform procedures in a standardized
manner, and that information is provided equally to
different family members.33
They mentioned that communication with professionals
enables them to be guided on the best way to participate in
care, avoiding risks to the child's health,19 and reinforced
the importance of the team reflecting on its role in
conveying information and guidance to family
members.38,42
Family members also suggested improvements directed
toward healthcare professionals: fall risk assessment,
greater attention to patient identification, implementation
and compliance with measures for the correct
prescription/administration of medications,39 increased
teamwork, handwashing, equipment sterilization,36
individualized care36,41, and care with affection and
empathy.39,41
In regard to suggestions for organizational improvement to
promote safety, family members recommend: greater
control and restriction of visits, increased attention to
infection control,4 greater guidance and supervision of
care,38 use of advanced technologies38,43 and an increase in
professional qualifications.43,44
They also suggest posting safety recommendations in
public areas of the units, such as proper hand hygiene
practices, increasing adherence among family members,
visits, and greater openness to dialogue with professionals
on this aspect.29
Conclusion
Through the results extracted from the included studies, it
was possible to address the scoping review questions. There
is little divergence in the perception of safety among
families of hospitalized children. Families can report safety
incidents in various aspects of care, with medication
administration being the incident with the highest number
of reports. They understand that patient safety goes beyond
Pensar Enfermagem / v.28 n.01 / February 2024 | 23
DOI: 10.56732/pensarenf.v28i1.298
Review Article
risk issues, also involving the relationship with healthcare
professionals.
There is a particular emphasis on communication and the
relationship they establish with healthcare professionals,
not neglecting aspects of practice and technique in care
delivery. The most frequently mentioned contributing
factor to unsafe care was a lack of communication, and
improvement suggestions seem to focus on increased
information transmission to families and greater attention
and vigilance by healthcare professionals for
hospitalized children.
Families are indeed attentive to the care provided and show
interest in participating in the safety promotion of their
children and being involved in care, which gives them a
greater sense of security and comfort. The diversity of
family perceptions may be related to different safety
conditions in various organizations and countries. Their
suggestions align with what is recommended for promoting
safety in healthcare organizations.
It is understood that families of hospitalized children
present a distinct view of the safety of hospitalized children,
providing a detached perspective. The current scoping
review is considered to provide results that raise awareness
among healthcare professionals about their care provision
concerning the safety of hospitalized children. Based on the
review results, a prevalence of studies conducted in the
USA and Brazil was identified. Given the relevance of the
topic, an increase in research studies in this area is
recommended in other countries.
Study Limitations
Study limitations identified include the potential risk of
omitting relevant studies not covered by the descriptors
and free terms in the initial search. However, to mitigate
this risk, the bibliographic references of selected studies
were consulted. Another limitation is the inability to obtain
two studies that could contain relevant data for the review,
even after contacting the authors. Additionally, the
inclusion of studies in Portuguese, English, and Spanish,
excluding studies in other languages, may have excluded
potentially important studies from this review.
Authors’ contributions
MSousa: Conception and design of the study; Collection of
data; Analysis and interpretation of data; Statistical analysis;
Writing of the manuscript.
MCorreia: Conception and design of the study; Data
collection; Analysis and interpretation of data; Statistical
analysis; Writing of the manuscript.
ENunes: Critical revision of the manuscript.
Conflicts of interest and Funding
No conflicts of interest were declared by the authors.
Acknowledgments
The authors are grateful for the support and guidance
provided by the Library of the Portuguese Catholic
University (UCP) in Lisbon with regard to the research
strategy carried out.
Sources of support / Financing
The study was not funded.
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