This is a revision of the previous American Academy of Pediatrics policy statement titled “Patient Safety in the Emergency Care Setting,” and is the first joint policy statement by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association to address pediatric patient safety in the emergency care setting. Caring for children in the emergency setting can be prone to medical errors because of a number of environmental and human factors. The emergency department (ED) has frequent workflow interruptions, multiple care transitions, and barriers to effective communication. In addition, the high volume of patients, high-decision density under time pressure, diagnostic uncertainty, and limited knowledge of patients’ history and preexisting conditions make the safe care of critically ill and injured patients even more challenging. It is critical that all EDs, including general EDs who care for the majority of ill and injured children, understand the unique safety issues related to children. Furthermore, it is imperative that all EDs practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This policy statement outlines the recommendations necessary for EDs to minimize pediatric medical errors and to provide safe care for children of all ages.

Over the last 2 decades, patient safety has become a key priority for health care systems because of increased recognition of the risks of medical care. Since the publication of the 2000 report of the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine), “To Err is Human: Building a Safer Health System,”1  there have been significant increases in research, education, collaboration among numerous organizations, and development of outcome measures to promote safety in the medical care arena. Despite such progress, medical errors and patient harm remain common.2,3 

Since the publication of the original American Academy of Pediatrics (AAP) policy statement on this topic,4  several specific policies of the AAP, American College of Emergency Physicians (ACEP), and Emergency Nurses Association (ENA) related to patient safety strategies have been published in the peer-reviewed medical literature, including pediatric readiness in the emergency department (ED), handoffs, patient- and family-centered care, and medication safety.58  In addition, the revised policy expands on the principles of pediatric patient safety in the AAP policy statement from the Council on Quality Improvement and Patient Safety9  to address elements specific to caring for pediatric patients in the emergency care setting. Of note, the revised policy statement is also intended for promoting pediatric safety in all emergency care settings, including general EDs caring for children and pediatric EDs.

The Joint Commission constructed a framework that health care organizations can use to accelerate their progress toward the ultimate goal of zero harm. The framework is organized around 3 major domains of change including: (1) commitment of leadership to the goal of zero harm, (2) promotion of safety culture, and (3) empowerment of the work force to employ robust process improvements tools.10  In addition, the Institute for Healthcare Improvement and Safe & Reliable Healthcare collaborated to develop the Framework for Safe, Reliable, and Effective Care. The framework consists of 2 foundational domains, culture and the learning system, along with 9 interrelated components, with engagement of patients and families at the core.11  The 9 components include leadership, 4 cultural components (psychological safety, accountability, teamwork and communication, and negotiation) and 4 components of the learning system (transparency, reliability, improvement and measurement, and continuous learning). This policy statement will address adopting these frameworks of The Joint Commission, as well as the Institute for Healthcare Improvement and Safe & Reliable Healthcare in the emergency care setting to provide resources and recommendations that promote pediatric patient safety.

  • Make patient safety in the ED a priority for hospital and ED leadership.

  • Ensure that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide emergency care for children, per the AAP, ACEP, ENA joint policy on pediatric readiness in the ED.5 

  • Support the presence of a pediatric ED quality and patient safety committee or pediatric representative on the ED quality and safety committee, which increases the culture of safety and addresses pediatric-specific safety issues.12 

  • Support the concepts and encourage acceptance of tenets of pediatric readiness in all EDs across communities at state and national levels.5 

  • Establish processes for ongoing quality improvement and regular assessment of pediatric readiness in the ED and develop a plan to address any deficiencies.

The main factors influencing patient safety culture in the ED are human, managerial, and organizational and environmental.13,14 

I. Factors That Influence People and Their Behavior

Patient- and Family-Centered Care
  • Acknowledge the family’s role in the health of the patient as one of the core principles of patient- and family-centered care to ensure patient safety.15 

  • Engage patients and families at all points of emergency care, including family presence during procedures and resuscitation, cultural sensitivity, communication, shared decision-making, coordination with the medical home, and discharge planning and instructions.7 

  • Establish a clear policy and procedure for family presence, supported by all levels of the hospital staff, including physician specialties, which will decrease family and staff anxiety when family is present during procedures and resuscitations7,16,17 

  • Support attention to the physical, emotional, and distinct medical needs of children. Having designated areas in a general ED allows for taking steps toward making the physical environment safer for children, such as locks on cabinets, and placing dangerous equipment (ie, the sharps containers) high and out of reach of children.

  • Support patient- and family-centered care and safe care of all children, including children and youth with special health care needs, such as children with intellectual disabilities, children who are nonverbal and have cerebral palsy, and children with deafness. This includes ensuring specific components of dignity and respect (such as listening to families), participation, collaboration, information and child-oriented resources, support for families, and environmental resources (eg, conducive and welcoming waiting room design and wait-time strategies).18 

  • Support the presence and expertise of a certified child life specialist in the ED that focuses on age-appropriate distraction techniques to minimize anxiety, fear, and need for sedation in children undergoing procedures such as intravenous line insertion, wound repair, and other invasive and painful procedures to positively affect the experience for the child and their caregiver, and help improve safety and satisfaction with the ED visit.1921  Training for nurses and physicians regarding distraction and pain-alleviating strategies is important especially in the absence of a child life specialists.

  • Encourage timely communication between the ED and the medical home to ensure safe and continuum of care.

  • Encourage seeking resources available at the Institute for Patient- and Family-Centered Care on the subject, including a self-assessment inventory specific to the ED.22 

Communication
  • Cultural competency, cultural humility

    • Acknowledge the impact of racial and/or ethnic disparities on many aspects of emergency care, such as recognizing disparities in analgesic management for children presenting with acute abdominal pain, appendicitis, and fractures2325 ; imaging26 ; and antibiotic prescriptions in viral infections.27 

    • Advocate for efforts to target implicit bias training and diversify the ED workforce, which has the potential to close some of the gaps in heath disparities in the emergency care settings.28,29 

    • Improve clinicians’ cultural competency and awareness of their own implicit bias on the safety and quality of care of children in emergency care settings by providing education in health equity.30  The fast pace and stressors in the ED environment may lead to cognitive shortcuts and greater use of stereotypes, which exacerbate implicit biases.28 

  • Language barriers

    • Identify language and cultural barriers in the emergency care setting, because they have a large impact on health care delivery and patient safety because of higher rates of medical errors and worse clinical outcomes.31,32  Patients with language, culture, and socioeconomic challenges are disproportionately at risk for experiencing preventable adverse events in the health care system.3335 

    • Implement shared decision-making practices and address issues of ethnic culture, literacy, and language barriers by using trained language interpreter services rather than bilingual relatives or limited clinician’s proficiency in the patient’s language.36,37  Lack of such resources can increase the risk of adverse safety events, return visits to the ED, or deviation from evidence-based guidelines in the emergency care setting.3841 

    • Expand available resources for beside ED interpreters, such as using tele-interpreter services, which include sign language.42 

Errors in Diagnosis in Pediatric Emergency Medicine
  • Recognize that diagnostic errors or delayed diagnoses can occur throughout all settings of care, including the ED. Such errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment.43 

  • Identify factors that can cause breakdown in the diagnostic process. These include patient factors (language barriers, lower health literacy, and altered mentation), provider factors (overconfidence, cognitive biases, inadequate training, loss of skills/competencies, drug use), and systems factors (such as lack of available resources and poorly designed electronic health system). System factors also include socioeconomic factors (disparities attributable to insurance, race, language barriers, social determinants of health) that predispose patients to diagnostic errors.43 

  • Become aware of common cognitive biases in the clinician that can lead to diagnostic error.

  • Systematically address diagnostic errors in the pediatric emergency care setting to provide high-quality and safe care.4448 

Shift Work/Burnout/Wellness

It has long been recognized that clinician factors, such as physician burnout, have a significant influence on the health care system in terms of productivity, care quality, and patient safety.4951  Burnout has led many physicians to consider reducing workload, retiring early, quitting, or even suicide.52  Clinicians’ mental health is also often affected by burnout.50 

  • Recognize clinician’s burnout and poor well-being as factors contributing to poor safety outcomes, such as incorrect medication orders, delayed care, and incorrect documentation, all of which contribute to diagnostic errors and patient harm.51 

  • Be aware of the potential impact of “off hour” shift work (evenings, nights, weekends, and holidays), changing shift assignment from day to night in the ED on premature burnout, as well as poor overall physical, cognitive, mood, and mental health.5356  All of these factors impact the potential to cause medical errors and risk to patient safety.56,57 

  • Consider using behavioral interventions such as light therapy, keeping a consistent shift, moderate caffeine consumption, and scheduled naps to minimize the short-term negative effects of a shifting sleep schedule. In addition, many of the risks of shift work are associated with metabolic syndrome and obesity. Therefore, encouraging all ED staff in keeping a healthy weight, exercising regularly, and adopting healthy eating habits might decrease such risks.

  • Take into account improvement in clinicians’ wellness when planning interventions to improve patient safety.53  It is also critical to advocate for governments and health policy makers to invest in the wellness of health care professionals, especially nursing, to counter workforce shortage, which was exacerbated during the coronavirus disease 2019 (COVID-19) pandemic in hospitals and EDs, to ensure a healthy population.58 

II. Managerial Factors

Psychological Safety and Reporting Close Calls
  • Enhance patient safety by using reports from frontline staff of near-misses and unsafe conditions to identify latent safety events. Such reporting is vital to continue to improve systems within the ED environment to ensure patient safety.59 

  • Encourage open communication and joint review and auditing (morbidity and mortality conferences or other mechanisms) of near-misses among ED physicians and ED nursing staff. That practice can help create “just culture” with no individual blame for errors, which can mitigate reluctance among clinicians to report and discourage the hiding of events.60 

  • Listen to families, as an underused source of data in emergency care settings, to learn about errors, especially preventable adverse events, many of which may not be otherwise recognized by the medical team or documented in the medical record or event reporting.61 

ED Crowding and Patient Safety
  • Recognize that ED crowding threatens pediatric patient safety and poses an increased risk of medical errors, including errors related to delays in providing emergent care.6268 

  • Support sustainable solutions to ED crowding that decrease input by increasing primary care access through extended hours of the medical home.69,70 

  • Support ED throughput by implementing a 5 level triage system with nurse-initiated, evidence-based, standardized protocols and order sets at the point of initial triage consistent with the recommendations of the AAP policy statement on overcrowding and ACEP standardized protocols for optimizing ED care and policy triage scale standardization.

  • Increase the use of clinical pathways, which could be included as part of the electronic health record (EHR) order set, in emergency care settings to decrease variation, increase efficiency, and improve safety for pediatric patients.76,77 

  • Improve the efficiency of care provided in emergency care settings to all acuity levels through the use of fast track and split flow on presentation.73,78,79 

  • Develop innovative ED staffing models that adapt to growing patient needs80  and introduce active bed management to facilitate timely ED to inpatient bed transfer and improve ED throughput.81,82  Active bed management includes improvement of hospital inpatient discharge processes, such as timely room cleaning, streamlining the discharge process, and conducting early rounds to determine patients’ eligibility for discharge. All of these practices can facilitate early transfer of patients from ED to the inpatient unit.

  • Address nursing and staff shortage in the inpatient unit, as well as in the ED, which can worsen during disasters such as during the COVID-19 pandemic. Such shortages can exacerbate the lack of available beds for admitted patients and also overburden nursing staff and create potential safety concerns.83 

  • Recognize that boarding, because of pediatric mental health issues, can worsen during disasters such as the COVID-19 pandemic, where mental health illnesses increased in frequency and severity.84  Disparities also exist in the outcomes of mental health; Black and Hispanic families are at risk for increased burden of grief because they experience higher mortality with certain illnesses such as with COVID-19, food insecurity, financial instability, and education interruption.85,86 

  • Advocate for increased mental health services in schools; integrate mental health into pediatric primary care; increase insurance coverage and payment for mental health in the ED, as well as follow-up care; and extend access to telehealth, all of which can decrease children and adolescents in crisis requiring ED visits. Advocacy for having appropriate mental health resources in the ED is critical for safety planning and postdischarge mental health outreach.

  • Explore research, education, and collaboration to develop and implement sustainable solutions to prevent and manage ED crowding.

III. Organizational and Environmental Factors

Teamwork/Team Training
  • Train ED staff in teamwork that teaches individuals to crosscheck each other’s actions using easy to remember acronyms87,88  and mnemonics such as those identified in the Children’s Hospital’s Solutions for Patient Safety-Zero Harm program to decrease the possibility of errors.89 

  • Optimize classroom education in teamwork by using simulation with specific scenarios to facilitate critical thinking skills, team interaction, and communication in the ED.88  Multidisciplinary teams benefit from preevent briefing, huddles, and postevent debriefing to help identify opportunities for improvement. Simulation training is an effective tool to modify safety attitudes and teamwork behaviors in the ED setting. Sustaining cultural and behavioral changes requires repeated practice opportunities and accountability of the entire ED team to complete such training.90 

  • Support the integration of team training in the physician, nursing, and emergency medical services training programs. The Agency for Healthcare Research and Quality provides information on several team-training programs with documented success in managing the challenging environment of the ED.91 

  • Incorporate a cultural broker (a go-between, one who advocates on behalf of another individual or group), when available, in the care team who can support the team to effectively address cultural differences in the patient’s practices and subsequently promote health equity and safety.92 

Emergency Department Shift Huddles
  • Conduct shift huddles among all staff involved in the patient’s care regularly in the ED to improve care coordination, relationships, and collaboration and strengthen the culture of safety.93,94  In addition, if time and circumstances allow, encourage less formal “spot” meetings at mid-shift to tackle any foreseeable concerns.

  • Support safety huddles/safety briefings, including daily check-ins. Huddles are recommended as a team building tool in Team Strategies and Tools to Enhance Performance and Patient Safety, which is an evidence-based teamwork system aimed at optimizing patient outcomes and safety to increase situational awareness and decrease error.95 

  • Support interprofessional and interdepartmental communication and collaboration between the ED and hospital units to improve patient flow from the ED to other units.96 

Handoffs in the Emergency Department

Communication errors are a contributing factor for approximately two-thirds of sentinel events,97  more than half of which involve handoff failures.98 

  • Recognize that patients requiring emergency care often transition across and within multiple care areas, including the prehospital setting, the ED, inpatient units, and medical homes. All of these transitions of care require handoffs to exchange mission-specific information, responsibility of care, and authority for treatment and procedures.6  The joint policy statement from the AAP, ACEP, and ENA on handoffs reviewed many recommendations to improve the safety practice in the ED setting.6 

  • Recognize that miscommunication and misinformation that starts in the ED may affect a patient’s inpatient and outpatient care, as well, because such information can be perpetuated throughout the entire patient encounter (and future encounters). Handoffs are a well-documented safety risk in the ED attributable to communication errors,6,100102  cognitive biases,102  and environmental factors.6 

  • Increase structured handoffs in the ED, which occur in less than 20% of handoffs from ED to inpatient care.103  Numerous models have been implemented and studied to improve the quality of handoffs, including checklists,102105  structured mnemonics,104,106,107  and handoff bundles.108,109  Examples of mnemonics include SBAR (situation, background, assessment, and recommendation),110  SOUND (synthesis, objective data, upcoming tasks, nursing input, and double check),104  ABC-SBAR (airway, breathing, circulation followed by situation, background, assessment, and recommendation),108  and I-PASS (illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by receiver).106 

  • Develop novel and innovative physician staffing models to allow overlapping shifts to decrease the number of handoffs that occur.111  Of note, the needs of each individual ED are unique. Therefore, the utilization and distribution of various staffing models utilizing physicians and other clinicians within the ED should be determined at the site level by local ED leadership.112 

  • Monitor patients in high-risk situations, in which key team members will visit such patients regularly to assess for change in clinical status. This situation includes handoff of a patient with an uncertain diagnosis or disposition, an unstable patient, a consultant-driven evaluation, a pending imaging study, deviations from a typical diagnosis or treatment plan, or a prolonged stay in the ED.113 

  • Explore further research comparing different handoff models in the ED setting to determine their effects on patient harm and clinical outcomes. In addition, best practices for handoffs need to be derived and validated so they can be implemented to improve patient safety in the emergency care setting.

It is critical for patient safety to ensure that staff has the ability to do what is necessary for patients in a timely manner, keeping the best interest of the patient in mind, including adapting to technology and developing and implementing strategies for providing safe and quality medical care. Information from frontline clinicians is critical to continue to improve any system process or strategies taken to increase patient safety.

  • Recognize the important role of information technology in improving health care safety and quality. In the modern ED, EHR functionally integrates bed management, patient flow, medication ordering and administration, abnormal study results, documentation, changes in clinical status, and disposition planning.

  • Increase the implementation of computerized physician order entry (CPOE) and clinical decision support (CDS) with electronic prescribing to reduce ordering medication errors. On the other hand, CPOE systems may not fully eliminate medication errors in children, because commercial or independently developed CPOE systems may fail to address critical unique pediatric dosing requirements.114  In addition, because true dosing alerts for medication errors can be overridden by clinicians, system refinements are necessary to reduce the high false-positive alert rate, which could lead to alert fatigue.115 

  • Develop CDS tools and integrate them into EHR to streamline workflows. An example of a guideline embedded within information systems to increase adherence to best practices is the successful CDS implementation in EHR of the 2 Pediatric Emergency Care Applied Research Network prediction rules to identify children at very low risk of clinically important traumatic brain injury. As a result, head computed tomography utilization rates decreased from 26.8% to 18.9%, with no increase in returns within 7 days and no significant missed diagnoses.116 

  • Identify technological solutions to medical safety concerns such as the use of electronic equipment (eg, programmable “smart” infusion pumps in neonates,117  barcoding to compare identification bands with medications). Such solutions have resulted in improved detection of medication calculations and administration errors.118 

  • Leverage the use of telehealth to enhance patient safety by connecting patients and pediatricians to remote specialist care. Telehealth can help in preventing unnecessary transfers and keeping patients in rural areas connected to the health care system when in-person visits are difficult to achieve.119122 

  • Recognize and support the evolving role of data science, and specifically artificial intelligence (AI) methods, in creating statistical models that can be integrated into CDS to improve patient safety and outcomes. In the ED, data science methods such as AI are increasingly being used for disease identification, admission or discharge prediction, and patient triage.123  AI is also being used to guide “smart” staffing decisions and resource allocation.124 

  • Use strategies for improving medication safety as outlined in the joint policy statement from the AAP, ACEP, and ENA on pediatric medication safety in the ED.8  This includes the development of a standard pediatric formulary that includes standard concentrations and dosage of high-risk and frequently used medications, such as resuscitation medications, vasoactive infusions, narcotics, and antibiotics, as well as look-alike and sound-alike medications.8 

  • Establish a process to ensure that body weight is measured and recorded in kilograms only to avoid inappropriate calculations.8,125,126 

  • Advocate for the integration of ED pharmacists, when possible, within the ED team to verify the preparation, dosing, dispensing, and reconciliation of medications administered in the ED, as well as drug education to heath care team and patients.127129  Having pharmacists in the ED directly or in a consultative fashion remotely (telepharmacy) may increase medication safety in the emergency care setting.

  • Establish the use of a distraction-free medication safety zone and implementation of an independent, 2-clinicians check process130  for high-alert medications, as suggested by the Institute for Safe Medication Practices and The Joint Commission.131,132  Patient-identification policies, consistent with The Joint Commission National Patient Safety Goals, should be implemented and monitored.130132 

  • Recognize risk factors for medication errors during ordering, preparation, and administration, such as not using the appropriate weight and performing medication calculations based on pounds instead of the recognized standard of kilograms, inappropriate calculations including tenfold-dosing errors, and making medication errors in the 5 rights of medication (the right patient, the right medication, the right dose, the right time, and the right route).

  • Establish safe sedation practices using guidelines such as the recently developed guidelines through a collaborative effort of the AAP and the American Academy of Pediatric Dentistry.133 

  • Advocate for policies to address timely tracking, reporting, and evaluation of patient safety events, and for the disclosure of medication errors or unanticipated outcomes. Education and training in medication error disclosure should be available to care providers who are assigned this responsibility.5,134,135 

  • Recognize that one of the fundamental foundations of pediatric disaster readiness is ensuring that general EDs are able to meet the needs of children on a daily basis. Thus, one of the key components of disaster preparedness for EDs is to be “pediatric ready.”5,125 

  • Ensure disaster planning takes into consideration the unique needs of children, especially those with access and functional needs and preexisting and complex medical conditions, as well as recognition of physical, developmental, and psychosocial differences, because the majority of children present to community hospital EDs.136 

  • Review ED disaster plans to ensure the safety of unaccompanied children, because during disasters, children may present unaccompanied by caregivers and unable to self-identify,137  and have an established protocols for patient tracking and family reunification.137 

  • Recognize that in a hazardous materials event, plans for decontamination of children should include attention to water temperature and pressure to reduce hypothermia and prevent further dermal injury.138 

  • Ensure that ED staff has practiced pediatric disaster plans, either through simulations or including children in disaster drills, given that disasters are “low-frequency, high-impact events.”139141 

  • Recognize that the mental health needs of children experiencing disasters can extend into adulthood.142  Therefore, hospital ED pediatric disaster plans may include identifying personnel to attend to the psychosocial and psychological needs of children to immediately decrease mental stress/trauma.

  • Ensure that staff and pediatric patients have adequate personal protective equipment to reduce transmission during infectious outbreaks.

  • Use available resources to improve pediatric disaster preparedness and response. The Emergency Medical Services for Children Improvement and Innovation Center has excellent resources for disaster preparedness.143  The AAP offers a resource kit and related tabletop exercises scenarios on a collaborative Web site, as well as a chapter within the Topical Collection Part One on Pediatric Preparedness Exercises.144,145  This kit was based on implementation of an AAP and Centers for Disease Control and Prevention virtual exercise.146 

Patient safety remains a critical priority for all clinicians caring for children who are ill and injured, as it is the foundation of high-quality health care. Clinicians must practice patient safety principles, support a culture of safety, and adopt best practices to continue to improve safety for all children seeking emergency care.

Madeline M. Joseph, MD, FAAP, FACEP

Prashant Mahajan, MD, MPH, MBA, FAAP

Sally K. Snow, RN, BSN, CPEN, FAEN

Brandon Ku, MD, FAAP

Mohsen Saidinejad, MD, MS, MBA

Gregory P. Conners, MD, MPH, MBA, FAAP, chairperson

James Callahan, MD, FAAP

Toni Gross, MD, MPH, FAAP

Madeline Joseph, MD, FAAP

Lois Lee, MD, MPH, FAAP

Elizabeth Mack, MD, MS, FAAP

Jennifer Marin, MD, MSc, FAAP

Suzan Mazor, MD, FAAP

Ronald Paul, MD, FAAP

Nathan Timm, MD, FAAP

Mark Cicero, MD, FAAP, National Association of EMS Physicians

Ann Dietrich, MD, FACEP, American College of Emergency Physicians

Andrew Eisenberg, MD, MHA, American Academy of Family Physicians

Mary Fallat, MD, FAAP, American College of Surgeons

Patricia Fanflik, PhD, MFT, MS, Maternal and Child Health Bureau

Cynthia Wright Johnson, MSN, RN, National Association of State EMS Officials

Sara Kinsman, MD, PhD, FAAP, Maternal and Child Health Bureau

Cynthiana Lightfoot, BFA, NRP, AAP Family Partnerships Network

Charles Macias, MD, MPH, FAAP, EMSC Innovation and Improvement Center

Diane Pilkey, RN, MPH, Maternal and Child Health Bureau

Katherine Remick, MD, FAAP, National Association of Emergency Medical Technicians

Sam Shahid, MBBS, MPH, American College of Emergency Physicians

Elizabeth Stone, RN, PhD, CPEN, Emergency Nurses Association

Joseph Wright, MD, MPH, FAAP, chairperson (2016–2020)

Javier Gonzalez del Rey, MD, MEd, FAAP

Brian Moore, MD, FAAP, National Association of EMS Physicians

Mohsen Saidinejad, MD, MBA, FAAP, FACEP, American College of Emergency Physicians

Sally Snow, RN, BSN, CPEN, FAEN, Emergency Nurses Association

Sue Tellez

Ann M. Dietrich, MD, chairperson

Kiyetta H. Alade, MD

Christopher S. Amato, MD,

Zaza Atanelov, MD

Marc Auerbach, MD

Isabel A. Barata, MD, FACEP

Lee S. Benjamin, MD, FACEP

Kathleen T. Berg, MD

Kathleen Brown, MD, FACEP

Cindy Chang, MD

Jessica Chow, MD

Corrie E. Chumpitazi, MD, MS, FACEP

Ilene A. Claudius, MD, FACEP

Joshua Easter, MD

Ashley Foster, MD

Sean M. Fox, MD, FACEP

Marianne Gausche-Hill, MD, FACEP

Michael J. Gerardi, MD, FACEP

Jeffrey M. Goodloe, MD, FACEP (Board Liaison)

Melanie Heniff, MD, JD, FAAP, FACEP

James (Jim) L. Homme, MD, FACEP

Paul T. Ishimine, MD, FACEP

Susan D. John, MD

Madeline M. Joseph, MD, FACEP

Samuel Hiu-Fung Lam, MD, MPH, RDMS, FACEP

Simone L. Lawson, MD

Moon O. Lee, MD, FACEP

Joyce Li, MD

Sophia D. Lin, MD

Dyllon Ivy Martini, MD

Larry Bruce Mellick, MD, FACEP

Donna Mendez, MD

Emory M. Petrack, MD, FACEP

Lauren Rice, MD

Emily A. Rose, MD, FACEP

Timothy Ruttan, MD, FACEP

Mohsen Saidinejad, MD, MBA, FACEP

Genevieve Santillanes, MD, FACEP

Joelle N. Simpson, MD, MPH, FACEP

Shyam M. Sivasankar, MD

Daniel Slubowski, MD

Annalise Sorrentino, MD, FACEP

Michael J. Stoner, MD, FACEP

Carmen D. Sulton, MD, FACEP

Jonathan H. Valente, MD, FACEP

Samreen Vora, MD, FACEP

Jessica J. Wall, MD

Dina Wallin, MD, FACEP

Theresa A. Walls, MD, MPH

Muhammad Waseem, MD, MS,

Dale P. Woolridge, MD, PhD, FACEP

Sam Shahid, MBBS, MPH

Marianne Gausche-Hill, MD, FACEP, FAAP, FAEMS

Cam Brandt, MS, RN, CEN, CPEN, chairperson

Krisi M. Kult, BSN, RN, CPEN, CPN

Justin J. Milici, MSN, RN, CEN, CPEN, CCRN, TCRN, FAEN

Nicholas A. Nelson, MS, RN, CEN, CPEN, CTRN, CCRN, NRP, TCRN

Michele A. Redlo, MSN, MPA, RN, CPEN

Maureen R. Curtis Cooper, BSN, RN, CEN, CPEN, FAEN, board liaison

Michele Redlo, MSN, MPA, BSN, RN, CPEN, chairperson

Krisi Kult, BSN, RN, CPEN, CPN

Katherine Logee, MSN, RN, NP, CEN, CPEN, CFRN, CNE, FNP-BC, PNP-BC

Dixie Elizabeth Bryant, MSN, RN, CEN, CPEN, NE-BC

Maureen Curtis Cooper, BSN, RN, CEN, CPEN, FAEN

Kristen Cline, BSN, RN, CEN, CPEN, CFRN, CTRN, TCRN, board liaison

Catherine Olson, MSN, RN

Drs Joseph, Ku, Mahajan, Saidinejad, and Ms Snow were each responsible for all aspects of writing and editing the document, and reviewing and responding to questions and comments from reviewers and the board of directors. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Published simultaneously in Pediatrics, Annals of Emergency Medicine, and Journal of Emergency Nursing.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-059674.

     
  • AAP

    American Academy of Pediatrics

  •  
  • ACEP

    American College of Emergency Physicians

  •  
  • AI

    artificial intelligence

  •  
  • CDS

    clinical decision support

  •  
  • COVID-19

    coronavirus disease 2019

  •  
  • CPOE

    computerized physician order entry

  •  
  • ED

    emergency department

  •  
  • EHR

    electronic health record

  •  
  • ENA

    Emergency Nurses Association

1
Institute of Medicine, Committee on Quality of Health Care in America
. In:
Kohn
LT
,
Corrigan
JM
,
Donaldson
MS
, eds.
To Err Is Human: Building a Safer Health Care System
.
Washington, DC
:
National Academies Press
;
2000
2
Walsh
KE
,
Bundy
DG
,
Landrigan
CP
.
Preventing health care-associated harm in children
.
JAMA
.
2014
;
311
(
17
):
1731
1732
3
Alghamdi
AA
,
Keers
RN
,
Sutherland
A
,
Ashcroft
DM
.
Prevalence and nature of medication errors and preventable adverse drug events in pediatric and neonatal intensive care settings: a systematic review
.
Drug Saf
.
2019
;
42
(
12
):
1423
1436
4
Krug
SE
,
Frush
K
.
American Academy of Pediatrics, Committee on Pediatric Emergency Medicine
.
Patient safety in the pediatric emergency care setting
.
Pediatrics
.
2007
;
120
(
6
):
1367
1375
5
Remick
K
,
Gausche-Hill
M
,
Joseph
MM
,
Brown
K
,
Snow
SK
,
Wright
JL
.
American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Surgery
;
American College of Emergency Physicians Pediatric Emergency Medicine Committee
;
Emergency Nurses Association Pediatric Committee
.
Pediatric readiness in the emergency department
.
Pediatrics
.
2018
;
142
(
5
):
e20182459
6
American Academy of Pediatrics Committee on Pediatric Emergency Medicine
;
American College of Emergency Physicians Pediatric Emergency Medicine Committee
;
Emergency Nurses Association Pediatric Committee
.
Handoffs: transitions of care for children in the emergency department
.
Pediatrics
.
2016
;
138
(
5
):
e20162680
7
Dudley
N
,
Ackerman
A
,
Brown
KM
,
Snow
SK
.
American Academy of Pediatrics Committee on Pediatric Emergency Medicine
;
American College of Emergency Physicians Pediatric Emergency Medicine Committee
;
Emergency Nurses Association Pediatric Committee
.
Patient- and family-centered care of children in the emergency department
.
Pediatrics
.
2015
;
135
(
1
):
e255
e272
8
Benjamin
L
,
Frush
K
,
Shaw
K
,
Shook
JE
,
Snow
SK
.
American Academy Of Pediatrics Committee on Pediatric Emergency Medicine
;
American College Of Emergency Physicians Pediatric Emergency Medicine Committee
;
Emergency Nurses Association Pediatric Emergency Medicine Committee
.
Pediatric Medication Safety in the Emergency Department
.
Pediatrics
.
2018
;
141
(
3
):
e20174066
9
Mueller
BU
,
Neuspiel
DR
,
Fisher
ERS
.
Council on Quality Improvement and Patient Safety, Committee on Hospital Care
.
Principles of pediatric patient safety: reducing harm due to medical care
.
Pediatrics
.
2019
;
143
(
2
):
e20183649
10
Chassin
MR
,
Loeb
JM
.
High-reliability health care: getting there from here
.
Milbank Q
.
2013
;
91
(
3
):
459
490
11
Frankel
A
,
Haraden
C
,
Federico
F
,
Lenoci-Edwards
J
.
A framework for safe, reliable, and effective care
.
[White paper]
Cambridge, MA
:
Institute for Healthcare Improvement and Safe & Reliable Healthcare
;
2017
12
Shaw
KN
,
Ruddy
RM
,
Olsen
CS
, et al.
Pediatric Emergency Care Applied Research Network
.
Pediatric patient safety in emergency departments: unit characteristics and staff perceptions
.
Pediatrics
.
2009
;
124
(
2
):
485
493
13
Tourani
S
,
Hassani
M
,
Ayoubian
A
,
Habibi
M
,
Zaboli
R
.
Analyzing and prioritizing the dimensions of patient safety culture in emergency wards using the TOPSIS technique
.
Glob J Health Sci
.
2015
;
7
(
4
):
143
150
14
Verbeek-Van Noord
I
,
Wagner
C
,
Van Dyck
C
,
Twisk
JW
,
De Bruijne
MC
.
Is culture associated with patient safety in the emergency department? A study of staff perspectives
.
Int J Qual Health Care
.
2014
;
26
(
1
):
64
70
15
Byczkowski
TL
,
Gillespie
GL
,
Kennebeck
SS
,
Fitzgerald
MR
,
Downing
KA
,
Alessandrini
EA
.
Family-centered pediatric emergency care: a framework for measuring what parents want and value
.
Acad Pediatr
.
2016
;
16
(
4
):
327
335
16
Vanhoy
MA
,
Horigan
A
,
Stapleton
SJ
, et al.
2017 ENA Clinical Practice Guideline Committee
;
ENA 2017 Board of Directors Liaison
;
2017 Staff Liaisons
.
Clinical practice guideline: family presence
.
J Emerg Nurs
.
2019
;
45
(
1
):
76.e1
76.e29
17
Zavotsky
KE
,
McCoy
J
,
Bell
G
, et al
.
Resuscitation team perceptions of family presence during CPR
.
Adv Emerg Nurs J
.
2014
;
36
(
4
):
325
334
18
Nicholas
DB
,
Muskat
B
,
Zwaigenbaum
L
, et al
.
Patient and family-centered care in the emergency department for children with autism
.
Pediatrics
.
2020
;
145
(
Suppl 1
):
S93
S98
19
Hall
JE
,
Patel
DP
,
Thomas
JW
,
Richards
CA
,
Rogers
PE
,
Pruitt
CM
.
Certified child life specialists lessen emotional distress of children undergoing laceration repair in the emergency department
.
Pediatr Emerg Care
.
2018
;
34
(
9
):
603
606
20
Sanchez Cristal
N
,
Staab
J
,
Chatham
R
,
Ryan
S
,
Mcnair
B
,
Grubenhoff
JA
.
Child life reduces distress and pain and improves family satisfaction in the pediatric emergency department
.
Clin Pediatr (Phila)
.
2018
;
57
(
13
):
1567
1575
21
Koller
D
.
Evidence-based practice statement summary: preparing children and adolescents for medical procedures
.
22
Institute for Patient- and Family-Centered Care
.
Patient- and family-centered care
.
Available at: https://www.ipfcc.org/about/pfcc.html. Accessed January 20, 2022
23
Johnson
TJ
,
Weaver
MD
,
Borrero
S
, et al
.
Association of race and ethnicity with management of abdominal pain in the emergency department
.
Pediatrics
.
2013
;
132
(
4
):
e851
e858
24
Goyal
MK
,
Kuppermann
N
,
Cleary
SD
,
Teach
SJ
,
Chamberlain
JM
.
Racial disparities in pain management of children with appendicitis in emergency departments
.
JAMA Pediatr
.
2015
;
169
(
11
):
996
1002
25
Goyal
MKJT
,
Johnson
TJ
,
Chamberlain
JM
, et al.
Pediatric Emergency Care Applied Research Network (Pecarn)
.
Racial and ethnic differences in emergency department pain management of children with fractures
.
Pediatrics
.
2020
;
145
(
5
):
e20193370
26
Marin
JR
,
Rodean
J
,
Hall
M
, et al
.
Racial and ethnic differences in emergency department diagnostic imaging at US children’s hospitals, 2016-2019
.
JAMA Netw Open
.
2021
;
4
(
1
):
e2033710
27
Goyal
MK
,
Johnson
TJ
,
Chamberlain
JM
, et al.
Pediatric Care Applied Research Network (PECARN)
.
Racial and ethnic differences in antibiotic use for viral illness in emergency departments
.
Pediatrics
.
2017
;
140
(
4
):
e20170203
28
Raphael
JL
,
Oyeku
SO
.
Implicit bias in pediatrics: an emerging focus in health equity research
.
Pediatrics
.
2020
;
145
(
5
):
e20200512
29
FitzGerald
C
,
Hurst
S
.
Implicit bias in healthcare professionals: a systematic review
.
BMC Med Ethics
.
2017
;
18
(
1
):
19
30
McMichael
B
,
Nickel
A
,
Duffy
EA
, et al
.
The impact of health equity coaching on patient’s perceptions of cultural competency and communication in a pediatric emergency department: an intervention design
.
J Patient Exp
.
2019
;
6
(
4
):
257
264
31
Agency for Healthcare Research and Quality
.
Chart book on patient safety
.
32
Johnstone
MJ
,
Kanitsaki
O
.
Culture, language, and patient safety: making the link
.
Int J Qual Health Care
.
2006
;
18
(
5
):
383
388
33
Flores
G
;
Committee On Pediatric Research
.
Technical report–racial and ethnic disparities in the health and health care of children
.
Pediatrics
.
2010
;
125
(
4
):
e979
e1020
34
Cheraghi-Sohi
S
,
Panagioti
M
,
Daker-White
G
, et al
.
Patient safety in marginalised groups: a narrative scoping review
.
Int J Equity Health
.
2020
;
19
(
1
):
26
35
Goenka
PK
.
Lost in translation: impact of language barriers on children’s healthcare
.
Curr Opin Pediatr
.
2016
;
28
(
5
):
659
666
36
Taveras
EM
,
Flores
G
.
Why culture and language matter: the clinical consequences of providing culturally and linguistically appropriate services to children in the emergency department
.
Clin Pediatr Emerg Med
.
2004
;
5
(
2
):
76
84
37
Agency for Healthcare Research and Quality
.
Improving patient safety systems for patients with limited English proficiency
.
38
Steinberg
EM
,
Valenzuela-Araujo
D
,
Zickafoose
JS
,
Kieffer
E
,
DeCamp
LR
.
The “battle” of managing language barriers in health care
.
Clin Pediatr (Phila)
.
2016
;
55
(
14
):
1318
1327
39
Mosquera
RA
,
Samuels
C
,
Flores
G
.
Family language barriers and special-needs children
.
Pediatrics
.
2016
;
138
(
4
):
e20160321
40
Gallagher
RA
,
Porter
S
,
Monuteaux
MC
,
Stack
AM
.
Unscheduled return visits to the emergency department: the impact of language
.
Pediatr Emerg Care
.
2013
;
29
(
5
):
579
583
41
Zamor
R
,
Byczkowski
T
,
Zhang
Y
,
Vaughn
L
,
Mahabee-Gittens
EM
.
Language barriers and the management of bronchiolitis in a pediatric emergency department
.
Acad Pediatr
.
2020
;
20
(
3
):
356
363
42
Fileccia
J
.
Sensitive care for the deaf: a cultural challenge
.
Creat Nurs
.
2011
;
17
(
4
):
174
179
43
Institute of Medicine, Committee on Diagnostic Error in Health Care
. In:
Balogh
EP
,
Miller
BT
,
Ball
JR
, eds.
Improving Diagnosis in Health Care
.
Washington, DC
:
National Academies Press
;
2015
44
Medford-Davis
LN
,
Singh
H
,
Mahajan
P
.
Diagnostic decision-making in the emergency department
.
Pediatr Clin North Am
.
2018
;
65
(
6
):
1097
1105
45
Mahajan
P
,
Basu
T
,
Pai
CW
, et al
.
Factors associated with potentially missed diagnosis of appendicitis in the emergency department
.
JAMA Netw Open
.
2020
;
3
(
3
):
e200612
46
Sundberg
M
,
Perron
CO
,
Kimia
A
, et al
.
A method to identify pediatric high-risk diagnoses missed in the emergency department
.
Diagnosis (Berl)
.
2018
;
5
(
2
):
63
69
47
Czolgosz
T
,
Cashen
K
,
Farooqi
A
,
Kannikeswaran
N
.
Delayed admissions to the pediatric intensive care unit: progression of disease or errors in emergency department management
.
Pediatr Emerg Care
.
2019
;
35
(
8
):
568
574
48
Mangus
CW
,
Mahajan
P
.
Common medical errors in pediatric emergency medicine
.
Clin Pediatr Emerg Med
.
2019
;
20
(
3
):
100714
49
Dewa
CS
,
Loong
D
,
Bonato
S
,
Thanh
NX
,
Jacobs
P
.
How does burnout affect physician productivity? A systematic literature review
.
BMC Health Serv Res
.
2014
;
14
:
325
50
Hayashino
Y
,
Utsugi-Ozaki
M
,
Feldman
MD
,
Fukuhara
S
.
Hope modified the association between distress and incidence of self-perceived medical errors among practicing physicians: prospective cohort study
.
PLoS One
.
2012
;
7
(
4
):
e35585
51
Tawfik
DS
,
Profit
J
,
Morgenthaler
TI
, et al
.
Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors
.
Mayo Clin Proc
.
2018
;
93
(
11
):
1571
1580
52
Stehman
CR
,
Testo
Z
,
Gershaw
RS
,
Kellogg
AR
.
Burnout, drop out, suicide: physician loss in emergency medicine, part I
.
West J Emerg Med
.
2019
;
20
(
3
):
485
494
53
Hall
LH
,
Johnson
J
,
Watt
I
,
Tsipa
A
,
O’Connor
DB
.
Healthcare staff wellbeing, burnout, and patient safety: a systematic review
.
PLoS One
.
2016
;
11
(
7
):
e0159015
54
Wisetborisut
A
,
Angkurawaranon
C
,
Jiraporncharoen
W
,
Uaphanthasath
R
,
Wiwatanadate
P
.
Shift work and burnout among health care workers
.
Occup Med (Lond)
.
2014
;
64
(
4
):
279
286
55
Øyane
NM
,
Pallesen
S
,
Moen
BE
,
Akerstedt
T
,
Bjorvatn
B
.
Associations between night work and anxiety, depression, insomnia, sleepiness and fatigue in a sample of Norwegian nurses
.
PLoS One
.
2013
;
8
(
8
):
e70228
56
Johnson
AL
,
Jung
L
,
Song
Y
,
Brown
KC
,
Weaver
MT
,
Richards
KC
.
Sleep deprivation and error in nurses who work the night shift
.
J Nurs Adm
.
2014
;
44
(
1
):
17
22
57
Kuhn
G
.
Circadian rhythm, shift work, and emergency medicine
.
Ann Emerg Med
.
2001
;
37
(
1
):
88
98
58
Turale
S
,
Nantsupawat
A
.
Clinician mental health, nursing shortages and the COVID-19 pandemic: Crises within crises
.
Int Nurs Rev
.
2021
;
68
(
1
):
12
14
59
Ruddy
RM
,
Chamberlain
JM
,
Mahajan
PV
, et al.
Pediatric Emergency Care Applied Research Network
.
Near-misses and unsafe conditions reported in a Pediatric Emergency Research Network
.
BMJ Open
.
2015
;
5
(
9
):
e007541
60
Paradiso
L
,
Sweeney
N
.
Just culture: it’s more than policy
.
Nurs Manage
.
2019
;
50
(
6
):
38
45
61
Khan
A
,
Furtak
SL
,
Melvin
P
,
Rogers
JE
,
Schuster
MA
,
Landrigan
CP
.
Parent-reported errors and adverse events in hospitalized children
.
JAMA Pediatr
.
2016
;
170
(
4
):
e154608
62
Sills
MR
,
Fairclough
D
,
Ranade
D
,
Kahn
MG
.
Emergency department crowding is associated with decreased quality of care for children
.
Pediatr Emerg Care
.
2011
;
27
(
9
):
837
845
63
Kennebeck
SS
,
Timm
NL
,
Kurowski
EM
,
Byczkowski
TL
,
Reeves
SD
.
The association of emergency department crowding and time to antibiotics in febrile neonates
.
Acad Emerg Med
.
2011
;
18
(
12
):
1380
1385
64
Shenoi
R
,
Ma
L
,
Syblik
D
,
Yusuf
S
.
Emergency department crowding and analgesic delay in pediatric sickle cell pain crises
.
Pediatr Emerg Care
.
2011
;
27
(
10
):
911
917
65
Bekmezian
A
,
Fee
C
,
Bekmezian
S
,
Maselli
JH
,
Weber
E
.
Emergency department crowding and younger age are associated with delayed corticosteroid administration to children with acute asthma
.
Pediatr Emerg Care
.
2013
;
29
(
10
):
1075
1081
66
Sagaidak
S
,
Rowe
BH
,
Ospina
MB
,
Rosychuk
RJ
.
Emergency department crowding negatively influences outcomes for children presenting with asthma: a population-based retrospective cohort study
.
Pediatr Res
.
2021
;
89
(
3
):
679
685
67
Sills
MR
,
Fairclough
DL
,
Ranade
D
,
Mitchell
MS
,
Kahn
MG
.
Emergency department crowding is associated with decreased quality of analgesia delivery for children with pain related to acute, isolated, long-bone fractures
.
Acad Emerg Med
.
2011
;
18
(
12
):
1330
1338
68
Tekwani
KL
,
Kerem
Y
,
Mistry
CD
,
Sayger
BM
,
Kulstad
EB
.
Emergency department crowding is associated with reduced satisfaction scores in patients discharged from the emergency department
.
West J Emerg Med
.
2013
;
14
(
1
):
11
15
69
Morley
C
,
Unwin
M
,
Peterson
GM
,
Stankovich
J
,
Kinsman
L
.
Emergency department crowding: a systematic review of causes, consequences and solutions
.
PLoS One
.
2018
;
13
(
8
):
e0203316
70
O’Malley
AS
.
After-hours access to primary care practices linked with lower emergency department use and less unmet medical need
.
Health Aff (Millwood)
.
2013
;
32
(
1
):
175
183
71
American Academy of Pediatrics, Committee on Pediatric Emergency Medicine
.
Overcrowding crisis in our nation’s emergency departments: is our safety net unraveling?
Pediatrics
.
2004
;
114
(
3
):
878
888
72
American College of Emergency Physicians, Emergency Practice Committee
.
Emergency department crowding: high impact solutions
.
73
Barata
I
,
Brown
KM
,
Fitzmaurice
L
,
Griffin
ES
,
Snow
SK
.
American Academy of Pediatrics Committee on Pediatric Emergency Medicine
;
American College of Emergency Physicians Pediatric Emergency Medicine Committee
;
Emergency Nurses Association Pediatric Committee
.
Best practices for improving flow and care of pediatric patients in the emergency department
.
Pediatrics
.
2015
;
135
(
1
):
e273
e283
74
American College of Emergency Physicians
.
Standardized protocols for optimizing emergency department care
.
75
American College of Emergency Physicians
.
Policy triage scale standardization
.
76
Lee
J
,
Rodio
B
,
Lavelle
J
, et al
.
The impact and safety of an updated anaphylaxis clinical pathway in a busy pediatric emergency department
.
J Allergy Clin Immunol
.
2017
;
139
(
2
):
AB222
77
Iqbal
SF
,
Brown
KM
.
Improving timeliness and reducing variability in asthma care through the use of clinical pathways
.
Clin Pediatr Emerg Med
.
2018
;
19
(
1
):
52
54
78
Arya
R
,
Wei
G
,
McCoy
JV
,
Crane
J
,
Ohman-Strickland
P
,
Eisenstein
RM
.
Decreasing length of stay in the emergency department with a split emergency severity index 3 patient flow model
.
Acad Emerg Med
.
2013
;
20
(
11
):
1171
1179
79
Copeland
J
,
Gray
A
.
A daytime fast track improves throughput in a single physician coverage emergency department
.
CJEM
.
2015
;
17
(
6
):
648
655
80
Hung
GR
,
Whitehouse
SR
,
O’Neill
C
,
Gray
AP
,
Kissoon
N
.
Computer modeling of patient flow in a pediatric emergency department using discrete event simulation
.
Pediatr Emerg Care
.
2007
;
23
(
1
):
5
10
81
Howell
E
,
Bessman
E
,
Kravet
S
,
Kolodner
K
,
Marshall
R
,
Wright
S
.
Active bed management by hospitalists and emergency department throughput
.
Ann Intern Med
.
2008
;
149
(
11
):
804
811
82
Barrett
L
,
Ford
S
,
Ward-Smith
P
.
A bed management strategy for overcrowding in the emergency department
.
Nurs Econ
.
2012
;
30
(
2
):
82
85
,
116
83
Ramsey
Z
,
Palter
JS
,
Hardwick
J
,
Moskoff
J
,
Christian
EL
,
Bailitz
J
.
Decreased nursing staffing adversely affects emergency department throughput metrics
.
West J Emerg Med
.
2018
;
19
(
3
):
496
500
84
Guessoum
SB
,
Lachal
J
,
Radjack
R
, et al
.
Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown
.
Psychiatry Res
.
2020
;
291
:
113264
85
Purtle
J
.
COVID-19 and mental health equity in the United States
.
Soc Psychiatry Psychiatr Epidemiol
.
2020
;
55
(
8
):
969
971
86
Krass
P
,
Doupnik
SK
.
Equity in emergency mental health care
.
Pediatrics
.
2021
;
147
(
5
):
e2020049843
87
Baker
D
,
Battles
J
,
King
H
.
New insights about team training from a decade of TeamSTEPPS
.
88
Brown
L
,
Overly
F
.
Simulation-based interprofessional team training
.
Clin Pediatr Emerg Med
.
2016
;
17
(
3
):
179
184
89
Lyren
A
,
Brilli
RJ
,
Zieker
K
,
Marino
M
,
Muething
S
,
Sharek
PJ
.
Children’s hospitals’ solutions for patient safety collaborative impact on hospital-acquired harm
.
Pediatrics
.
2017
;
140
(
3
):
e20163494
90
Patterson
MD
,
Geis
GL
,
LeMaster
T
,
Wears
RL
.
Impact of multidisciplinary simulation-based training on patient safety in a paediatric emergency department
.
BMJ Qual Saf
.
2013
;
22
(
5
):
383
393
91
Agency for Healthcare Research and Quality, Patient Safety Network
.
Teamwork training
.
Available at: https://psnet.ahrq.gov/primers/primer/8. Accessed October 10, 2020
92
Goode
T
,
Sockalingam
S
,
Snyder
LL
, et al.
National Center for Cultural Competence, Georgetown University Center for Child and Human Development
.
Bridging the cultural divide in health care settings: the essential role of cultural broker programs
.
93
Provost
SM
,
Lanham
HJ
,
Leykum
LK
,
McDaniel
RR
Jr
,
Pugh
J
.
Health care huddles: managing complexity to achieve high reliability
.
Health Care Manage Rev
.
2015
;
40
(
1
):
2
12
94
Brady
PW
,
Muething
S
,
Kotagal
U
, et al
.
Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events
.
Pediatrics
.
2013
;
131
(
1
):
e298
e308
95
Agency for Healthcare Research and Quality
.
Daily huddles
.
96
McBeth
CL
,
Durbin-Johnson
B
,
Siegel
EO
.
Interprofessional huddle: one children’s hospital’s approach to improving patient flow
.
Pediatr Nurs
.
2017
;
43
(
2
):
71
76
97
The Joint Commission
.
Sentinel event statistics data: root causes by event type
.
98
The Joint Commission
.
Improving hand-off communications: meeting national patient safety goal 2E
.
Jt Comm Perspect Patient Saf
.
2006
;
6
(
8
):
9
15
99
Venkatesh
AK
,
Curley
D
,
Chang
Y
,
Liu
SW
.
Communication of vital signs at emergency department handoff: opportunities for improvement
.
Ann Emerg Med
.
2015
;
66
(
2
):
125
130
100
Maughan
BC
,
Lei
L
,
Cydulka
RK
.
ED handoffs: observed practices and communication errors
.
Am J Emerg Med
.
2011
;
29
(
5
):
502
511
101
Horwitz
LI
,
Meredith
T
,
Schuur
JD
,
Shah
NR
,
Kulkarni
RG
,
Jenq
GY
.
Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care
.
Ann Emerg Med
.
2009
;
53
(
6
):
701
10.e4
102
Croskerry
P
.
From mindless to mindful practice--cognitive bias and clinical decision making
.
N Engl J Med
.
2013
;
368
(
26
):
2445
2448
103
Kessler
C
,
Scott
NL
,
Siedsma
M
,
Jordan
J
,
Beach
C
,
Coletti
CM
.
Interunit handoffs of patients and transfers of information: a survey of current practices
.
Ann Emerg Med
.
2014
;
64
(
4
):
343
349.e5
104
Gopwani
PR
,
Brown
KM
,
Quinn
MJ
,
Dorosz
EJ
,
Chamberlain
JM
.
SOUND: a structured handoff tool improves patient handoffs in a pediatric emergency department
.
Pediatr Emerg Care
.
2015
;
31
(
2
):
83
87
105
Mullan
PC
,
Macias
CG
,
Hsu
D
,
Alam
S
,
Patel
B
.
A novel briefing checklist at shift handoff in an emergency department improves situational awareness and safety event identification
.
Pediatr Emerg Care
.
2015
;
31
(
4
):
231
238
106
Starmer
AJ
,
Spector
ND
,
Srivastava
R
,
Allen
AD
,
Landrigan
CP
,
Sectish
TC
;
I-PASS Study Group
.
I-pass, a mnemonic to standardize verbal handoffs
.
Pediatrics
.
2012
;
129
(
2
):
201
204
107
McCrory
MC
,
Aboumatar
H
,
Custer
JW
,
Yang
CP
,
Hunt
EA
.
“ABC-SBAR” training improves simulated critical patient hand-off by pediatric interns
.
Pediatr Emerg Care
.
2012
;
28
(
6
):
538
543
108
Bigham
MT
,
Logsdon
TR
,
Manicone
PE
, et al
.
Decreasing handoff-related care failures in children’s hospitals
.
Pediatrics
.
2014
;
134
(
2
):
e572
e579
109
Starmer
AJ
,
Spector
ND
,
Srivastava
R
, et al.
I-PASS Study Group
.
Changes in medical errors after implementation of a handoff program
.
N Engl J Med
.
2014
;
371
(
19
):
1803
1812
110
Denham
CR
.
SBAR for patients
.
J Patient Saf
.
2008
;
4
(
1
):
38
48
111
Yoshida
H
,
Rutman
LE
,
Chen
J
, et al
.
Waterfalls and handoffs: a novel physician staffing model to decrease handoffs in a pediatric emergency department
.
Ann Emerg Med
.
2019
;
73
(
3
):
248
254
112
American College of Emergency Physicians
.
Acep policy on staffing models and the role of the emergency department medical director
.
113
Cheung
DS
,
Kelly
JJ
,
Beach
C
, et al.
Section of Quality Improvement and Patient Safety, American College of Emergency Physicians
.
Improving handoffs in the emergency department
.
Ann Emerg Med
.
2010
;
55
(
2
):
171
180
114
Zorc
JJ
,
Hoffman
JM
,
Harper
MB
.
IT in the ED: a new section of pediatric emergency care
.
Pediatr Emerg Care
.
2012
;
28
(
12
):
1399
1401
115
Sethuraman
U
,
Kannikeswaran
N
,
Murray
KP
,
Zidan
MA
,
Chamberlain
JM
.
Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department
.
Acad Emerg Med
.
2015
;
22
(
6
):
714
719
116
Atabaki
SM
,
Jacobs
BR
,
Brown
KM
, et al
.
Quality improvement in pediatric head trauma with PECARN rules implementation as computerized decision support
.
Pediatr Qual Saf
.
2017
;
2
(
3
):
e019
117
Melton
KR
,
Timmons
K
,
Walsh
KE
,
Meinzen-Derr
JK
,
Kirkendall
E
.
Smart pumps improve medication safety but increase alert burden in neonatal care
.
BMC Med Inform Decis Mak
.
2019
;
19
(
1
):
213
118
Damhoff
HN
,
Kuhn
RJ
,
Baker-Justice
SN
.
Medication preparation in pediatric emergencies: comparison of a web-based, standard-dose, bar code-enabled system and a traditional approach
.
J Pediatr Pharmacol Ther
.
2014
;
19
(
3
):
174
181
119
Schinasi
DA
,
Atabaki
SM
,
Lo
MD
,
Marcin
JP
,
Macy
M
.
Telehealth in pediatric emergency medicine
.
Curr Probl Pediatr Adolesc Health Care
.
2021
;
51
(
1
):
100953
120
Varma
S
,
Schinasi
DA
,
Ponczek
J
, et al
.
A retrospective study of children transferred from general emergency departments to a pediatric emergency department: which transfers are potentially amenable to telemedicine?
J Pediatr
.
2021
;
230
:
126
132.e1
121
Dharmar
M
,
Romano
PS
,
Kuppermann
N
, et al
.
Impact of critical care telemedicine consultations on children in rural emergency departments
.
Crit Care Med
.
2013
;
41
(
10
):
2388
2395
122
Ray
KN
,
Demirci
JR
,
Bogen
DL
,
Mehrotra
A
,
Miller
E
.
Optimizing telehealth strategies for subspecialty care: recommendations from rural pediatricians
.
Telemed J E Health
.
2015
;
21
(
8
):
622
629
123
Shafaf
N
,
Malek
H
.
Applications of machine learning approaches in emergency medicine; a review article
.
Arch Acad Emerg Med
.
2019
;
7
(
1
):
34
124
John Hopkins Medicine
.
Center for Data Science in Emergency Medicine
.
125
Gausche-Hill
M
,
Ely
M
,
Schmuhl
P
, et al
.
A national assessment of pediatric readiness of emergency departments
.
JAMA Pediatr
.
2015
;
169
(
6
):
527
534
126
Doherty
C
,
Mc Donnell
C
.
Tenfold medication errors: 5 years’ experience at a university-affiliated pediatric hospital
.
Pediatrics
.
2012
;
129
(
5
):
916
924
127
American College of Emergency Physicians
.
Clinical pharmacist services in the emergency department
.
128
American Society of Health-System Pharmacists
.
ASHP guidelines on emergency medicine pharmacist services
.
129
Patanwala
AE
,
Sanders
AB
,
Thomas
MC
, et al
.
A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department
.
Ann Emerg Med
.
2012
;
59
(
5
):
369
373
130
Subramanyam
R
,
Mahmoud
M
,
Buck
D
,
Varughese
A
.
Infusion medication error reduction by two-person verification: a quality improvement initiative
.
Pediatrics
.
2016
;
138
(
6
):
e20154413
131
Institute for Safe Medication Practices (ISMP)
.
ISMP targeted medication safety best practices for hospitals
.
Available at: https://www.ismp.org/guidelines/best-practices-hospitals. Accessed January 28, 2022
132
The Joint Commission
.
National patient safety goals effective January 2022 for the Critical Access Hospital Program
.
133
Coté
CJ
,
Wilson
S
.
American Academy of Pediatrics
;
American Academy of Pediatric Dentistry
.
Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures
.
Pediatrics
.
2019
;
143
(
6
):
e20191000
134
Koller
D
,
Rummens
A
,
Le Pouesard
M
, et al
.
Patient disclosure of medical errors in paediatrics: A systematic literature review
.
Paediatr Child Health
.
2016
;
21
(
4
):
e32
e38
135
Committee on Medical Liability and Risk Management
;
Council on Quality Improvement and Patient Safety
.
Disclosure of adverse events in pediatrics
.
Pediatrics
.
2016
;
138
(
6
):
e20163215
136
Needle
S
,
Wright
J
.
Disaster Preparedness Advisory Council
;
Committee on Pediatric Emergency Medicine
.
Ensuring the health of children in disasters
.
Pediatrics
.
2015
;
136
(
5
):
e1407
e1417
137
American Academy of Pediatrics, Disaster Preparedness Advisory Council
;
Massachusetts General Hospital Center for Disaster Medicine
.
Family reunification following disasters: a planning tool for health care facilities
.
138
Chung
S
,
Baum
CR
,
Nyquist
AC
.
Disaster Preparedness Advisory Council, Council On Environmental Health, Committee On Infectious Diseases
.
Chemical-biological terrorism and its impact on children
.
Pediatrics
.
2020
;
145
(
2
):
e20193749
139
Schonfeld
DJ
,
Melzer-Lange
M
,
Hashikawa
AN
,
Gorski
PA
.
Council on Children and Disasters, Council on Injury, Violence, and Poison Prevention, Council on School Health
.
Participation of children and adolescents in live crisis drills and exercises
.
Pediatrics
.
2020
;
146
(
3
):
e2020015503
140
Hewett
EK
,
Nagler
J
,
Monuteaux
MC
, et al
.
A hazardous materials educational curriculum improves pediatric emergency department staff skills
.
AEM Educ Train
.
2017
;
2
(
1
):
40
47
141
Bank
I
,
Khalil
E
.
Are pediatric emergency physicians more knowledgeable and confident to respond to a pediatric disaster after an experiential learning experience?
Prehosp Disaster Med
.
2016
;
31
(
5
):
551
556
142
Amsel
L
,
Cheslak-Postava
K
,
Musa
G
, et al
.
The broad impact of childhood trauma: physical-psychiatric comorbidity in a cohort of individuals exposed to 9/11 in childhood
.
Presented at: 175th Annual Meeting of the American Psychiatric Association
,
San Francisco, California
;
May 18-22, 2019
; p
8
124
143
Emergency Medical Services for Children Improvement and Innovation Center
.
Pediatric Disaster Preparedness Toolkit
.
144
American Academy of Pediatrics
.
Pediatric tabletop exercise resource kit and other key resources for disaster preparedness
.
145
American Academy of Pediatrics
.
Pediatric disaster preparedness and response topical collection chapter 6: pediatric preparedness exercises
.
146
So
M
,
Dziuban
EJ
,
Franks
JL
, et al
.
Extending the reach of pediatric emergency preparedness: a virtual tabletop exercise targeting children’s needs
.
Public Health Rep
.
2019
;
134
(
4
):
344
353