Background & Objectives Little is known about how parents think about neonatal intensive care unit (NICU) safety. Due to their physiologic immaturity and small size, infants in NICUs are especially vulnerable to injury from their medical care. Campaigns are underway to integrate patients and family members into patient safety. This study aimed to describe how parents of infants in the NICU conceptualize patient safety and what kinds of concerns they have about safety. Methods This mixed-methods study employed questionnaires, interviews, and observation with parents of infant patients in an academic medical centre NICU. Measures included parent stress, family-centredness, and types of safety concerns. Results 46 parents completed questionnaires and 14 of these parents also participated in 10 interviews (including 4 couple interviews). Infants had a range of medical and surgical problems, including prematurity, congenital diaphragmatic hernia, and congenital cardiac disease. Parents were positive about their infants’ care and had low levels of concern about the safety of procedures. Parents reporting more stress had more concerns. We identified three overlapping domains in parent’s conceptualizations of safety in the NICU, including physical, developmental, and emotional safety. Parents demonstrated sophisticated understanding of how environmental, treatment, and personnel factors could potentially influence their infants’ developmental and emotional health. Conclusions Parents have safety concerns that cannot be addressed solely by reducing errors in the NICU. Parent engagement strategies that respect parents as partners in safety and address how clinical treatment articulates with physical, developmental, and emotional safety domains may result in safety improvements.

Objective To describe parents’ perspectives and likelihood of speaking up about safety concerns in the NICU and identify barriers and facilitators to parents speaking up. Design Exploratory, qualitatively-driven, mixed-methods design using questionnaires, interviews, and observations with parents of newborns in the NICU. The qualitative investigation was based on constructivist grounded theory. Quantitative measures included ratings and free text responses about likelihood of speaking up in response to a hypothetical scenario about lack of clinician hand hygiene. Qualitative and quantitative analyses were integrated in the final interpretation. Setting A 50-bed, US, academic medical center, open-bay NICU. Participants Forty-six parents completed questionnaires, 14 of whom were also interviewed. Results Most parents (75%) rated themselves likely or very likely to speak up in response to lack of hand hygiene; 25% of parents rated themselves unlikely to speak up in the same situation. Parents engaged in a complex process of Navigating the work of speaking up in the NICU that entailed learning the NICU, being deliberate about decisions to speak up, and at times choosing silence as a safety strategy. Decisions about how and when to speak up were influenced by multiple factors including knowing the newborn, knowing the team, having a defined pathway for voicing concerns, clinician approachability, clinician availability and friendliness, and clinician responsiveness. Conclusions To engage parents as full partners in safety, clinicians need to recognize the complex social and personal dimensions of the NICU experience that influence parents’ willingness to speak up about their safety concerns.