SAFER Care: Improving Discharge Communication at a Tertiary Care Children’s Hospital

From the 2019 HVPAA National Conference

Dr. Audrey Uong (Children’s Hospital at Montefiore), Dr. Kaitlyn Philips (Children’s Hospital at Montefiore), Dr. Julie Dunbar (Children’s Hospital at Montefiore), Dr. Priya Jain (Children’s Hospital at Montefiore), Dr. Katherine O’Connor (Children’s Hospital at Montefiore), Dr. Rachel Offenbacher (Children’s Hospital at Montefiore), Dr. Kethia Eliezer (Children’s Hospital at Montefiore), Dr. Jessica Tugetman (Children’s Hospital at Montefiore), Ms. Courtney Pilnick (Children’s Hospital at Montefiore), Ms. Victoria Kiely (Children’s Hospital at Montefiore), Ms. Karlene Bennett-Wynter (Children’s Hospital at Montefiore), Ms. Anjali Modi (Children’s Hospital at Montefiore), Ms. Meghan Kelly (Children’s Hospital at Montefiore), Dr. Patricia Hametz (Children’s Hospital at Montefiore), Dr. Michael L. Rinke (Children’s Hospital at Montefiore)


1 in 5 pediatric patients suffer from preventable medical errors or adverse events related to hospital discharge. Current literature lacks definitive evidence on how to effectively standardize and implement discharge processes to reduce risks and improve outcomes in an urban, high-risk pediatric population. Our objective is to investigate if a multi-modal quality improvement intervention increases caregiver knowledge of 7 key discharge instructions after discharge from a hospital medicine team.


We used the Model for Improvement and an inter-professional team to develop, implement and test interventions to improve discharge communication at a tertiary care children’s hospital. We created the SAFER Care acronym to encourage standard, comprehensive discharge communication. Plan-Do-Study-Act cycles included diagnosis-specific electronic medical record “smart phrases”, educational initiatives for trainees and nurses, discharge worksheets for families, deliberate practice, data feedback, and SAFER Care signage. We aimed for a convenience sample of 10-15 caregivers/week during the pre-intervention period, and 5 caregivers/week during the post-intervention period. Caregivers were surveyed by phone within 1-4 days of discharge to assess effectiveness of interventions. Data were collected from December 2017 to March 2019. Our primary outcome is the percentage of caregivers accurately responding all questions related to discharge care, comparing pre and post intervention periods. Data were plotted on a run chart using Nelson Rules, and interrupted time series analysis (ITSA) was calculated.


Pre-intervention data (172 caregivers) show that only 35% of caregivers accurately respond all 7 key discharge questions. Post-intervention data (263 caregivers) show 60% of caregivers accurately respond all 7 key discharge questions, a statistically significant change of 25% based on Nelson Rules (Figure 1). There was no difference in caregiver response accuracy in patients discharged over the weekend versus weekday (56% vs 55%). ITSA analysis suggests a statistically significant increase in percentage of caregivers accurately responding all discharge care questions (p=0.01).


An inter-professional team successfully devised multi-modal interventions to improve the quality of discharge communication and significantly increased parental knowledge of discharge instructions in a high-risk, low health literacy population.

Clinical Implications

This initiative was widely adopted (over 89% of all discharge paperwork used SAFER Care post-intervention). Improved caregiver awareness and knowledge of discharge instructions may decrease poor outcomes related to transitions of care.


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