Patient safety is a priority for health care institutions. In the emergency care setting, the risk of adverse events (AEs) increases on account of the high workloads and the need for rapid decision-making with limited clinical information. Furthermore, the care of pediatric patients requires particular attention with regard to safety on account of their particular physiological characteristics, the need to calculate doses based on weight, their dependency on their caregivers and the need to adapt care settings and communication to their age and developmental level.1

In this context, the involvement of patients and families is key to improving pediatric patient safety.2 This principle is reflected in Strategic Objective 4 del Global Patient Safety Action Plan 2021–2030 of the World Health Organization,3 which establishes the need to engage and educate patients and families to improve health care safety. In line with this approach, we conducted a study with the aim of assessing the perceived safety of families in the hospital-based emergency care setting as well as their contribution to the identification of risks and to improving care quality.

The study was a survey conducted in a tertiary care children’s hospital that manages 110 000 emergency visits a year. We developed a questionnaire (Appendix B) that was based on previously published tools designed to assess patient experience and safety adapted to the pediatric emergency care setting, which was reviewed by a multidisciplinary team.

The questionnaire was used to collect data on sociodemographic and clinical characteristics, aspects related to the health care experience, trust in the care team, perceived risk and possible incidents identified during the care episode. To assess the concordance between the incidents reported by patients and those reported by providers, we reviewed the health records of the involved patients corresponding to the study period. We classified incidents by type (medication error or procedure error) and severity (serious and not serious). We used a simplified classification because we assumed that patients and families did not have expert knowledge on the subject of patient safety. The study was approved by the ethics committee for research with medicines of the hospital (PIC-180-23).

Throughout November 2024, the customer service department emailed the study questionnaire along with the patient experience questionnaire that is systematically sent 24 h after discharge from the emergency department. It included the item “How likely are you to recommend this service [emergency care department] to family or friends?” to calculate the Net Promoter Score (a metric used in health care to evaluate the experience and satisfaction of patients/users).4 We received 452 responses (response rate, 4.8%). Table 1 summarizes the characteristics of the visits. In terms of satisfaction, 78.8% (95% CI, 75.1%–82.4%) were promoters of the center (rated the likelihood that they would recommend it with 9 or 10 points), 92.9% (95% CI, 90.6%–95.2%) felt heard by the care team, and 86.1% (95% CI, 83%–89.2%) reported having received adequate information. As regards perceived safety, 76.7% (95% CI, 72.5 %–80,2%) reported a high level of trust in the institution and 75.1% (95% CI, 71.1–78.9 %) a high level of trust in its staff. When asked about the perceived probability of experiencing a health care incident, 5.3% (95% CI, 3.3%–7.3%) rated it as probable. Based on the perception of families, the main causes of errors were lack of time (50%), fatigue (39.8%), lack of organization at the hospital (34.9%), insufficient resources (28.5%) and limited training of professionals (6.6%). Finally, 7.5% reported complications related to procedures or medication during the care episode. Families reported 31 incidents, of which 13 were real safety incidents (8 procedure; 5 medication), and providers reported 18 incidents (12 procedure; 6 medication), with no concordance between the two groups. There were no incidents that caused harm to a patient, although families categorized eight incidents as serious (eg, delay in the administration of an antipyretic).

The survey results reveal a high user satisfaction and a substantial perceived safety. These findings are consistent with those of previous studies, which highlight that satisfaction and effective communication with health care professionals are closely associated with the perceived safety of families. Similarly, participants considered the occurrence of AEs unlikely, a perception that could be influenced by limited knowledge of their actual incidence.5 However, the classification of some incidents as serious by families, despite the absence of actual harm to the patient, probably reflects an increase in perceived severity in association with the emotional impact and the subjective perception of potential risk, rather than objective clinical severity. With respect to the causes of errors, families highlighted the lack of time associated with excessive workloads and time pressure as critical risk factors in pediatric emergency care, factors that had already been identified in this care setting.1

The incidents identified by families did not coincide with those reported by providers or documented in the health records, highlighting the value of their perspective as a complementary source of information on safety risks, even in lower-acuity patients (triage level IV-V). Therefore, the systematic inclusion of the caregivers’ perspective enables the detection of risks that could go unnoticed by health care teams6,7 or that are not notified even when detected.

One of the main limitations of the study is the low response rate, although the characteristics of the sample were similar to those of the total managed population according to the data recorded by the hospital’s emergency department, which likely reduces the potential selection bias. The simplified incident classification may have affected the rating of their perceived severity, although it is unlikely that serious incidents were overlooked. Furthermore, since this was a single-center study, the results should be interpreted with caution and not extrapolated without performance of multicenter studies.

In conclusion, although emergency care was perceived as safe, a significant proportion of families identified risks. Incorporating their perspective is key, ethically as well as strategically, to improving the safety and quality of patient-centered care.