Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.

Over the last decade, patient safety, which is defined as the prevention of harm to patients,1  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 harm to patients remain common.2,3 

Caring for children in the emergency care setting can be prone to safety concerns because of a number of environmental and human factors. The emergency department (ED) environment has frequent workflow interruptions, multiple care transitions, and inherent barriers to effective communication. In addition, the ED’s high volume of patients, high decision density under time pressure, high levels of diagnostic uncertainty, and limited knowledge of patients’ history and preexisting conditions make the safe care of critically ill and injured patients even more challenging.4  It is imperative to look for best practices and provide strategies and recommendations to improve pediatric patient safety in the emergency care setting.

This document references several specific policies related to pediatric patient safety strategies that have been published in the last several years. This includes pediatric readiness in the ED, handoffs, patient- and family-centered care, and medication safety.58  In addition, this technical report expands on the principles in the American Academy of Pediatrics (AAP) policy statement “Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care”9  to address patient safety elements specific to caring for pediatric patients in the emergency care setting. This report is also intended for promoting pediatric safety in all emergency care settings, including general EDs caring for children and pediatric EDs.

One strategy to organize thinking about complicated health care systems is to categorize them into levels, such as micro, meso, and macro levels. This framework can provide understanding of the different points at which the patient interacts with the health care organization and highlight where potential safety measures can be effective. As such, the ED is considered a microsystem in which patients, families, and care teams meet and where quality and safe medical care is provided. On the other hand, the ED is part of multiple and interrelated microsystems (such as the laboratory and radiology departments), which is called the mesosystem, that could impact the quality and safety of medical care of ED patients. Such a system may be empowered and held accountable by the overarching macrosystem, such as a hospital or integrated health system safety policies.10 

In the safety arena, most macrosystems aim to become high-reliability organizations (HROs), which are those that operate in a high-risk environment but maintain very low rates of injury or harm. The concept of an HRO is attractive for health care macrosystems because of the complexity of operations and the risk of significant and even potentially catastrophic consequences when failures occur. The 5 central principles of HROs are: (1) sensitivity to operations (ie, heightened awareness of the state of relevant systems and processes); (2) reluctance to simplify (ie, the acceptance that work is complex, with the potential to fail in new and unexpected ways); (3) preoccupation with failure (ie, to view near misses as opportunities to improve, rather than proof of success); (4) deference to expertise (ie, to value insights from staff with the most pertinent safety knowledge over those with greater seniority); and (5) practicing resilience (ie, to prioritize emergency training for many unlikely, but possible, system failures).11 

High reliability means maintenance of consistent excellence in quality and safety across all services. 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) safety culture; and (3) empowerment of the workforce to employ robust process improvement tools to address the improvement opportunities they find and drive significant and lasting change.12  In addition, the Institute for Healthcare Improvement and Safe and 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.13  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).13 

This technical report addresses adopting The Joint Commission and Institute for Healthcare Improvement frameworks in the pediatric emergency care setting to promote patient safety.

Safety is a property of the clinical microsystem that can be achieved only through a systematic application of a broad array of process, equipment, organization, supervision, training, and teamwork changes. To achieve safety, hospital and ED leadership (macro- and microsystems) should set the stage for making safety a priority, not only for the organization, but also in the ED by supporting the ED to create innovative strategies for improvement and to achieve pediatric readiness to provide emergency care for children and adolescents.

The majority of children who are ill and injured are brought to community hospital EDs. To ensure safe and quality emergency care for children, it is imperative that hospitals or health care systems’ leadership ensure that all EDs have the appropriate resources (medications, age-appropriate equipment, policies, and education) and capable staff to provide such care. The joint policy statement from the AAP, American College of Emergency Physicians (ACEP), and Emergency Nurses Association (ENA) on pediatric readiness in the ED5  includes recommendations regarding current information on equipment, medications, supplies, and personnel that are considered critical for managing pediatric emergencies in EDs. That policy statement offered several recommendations that addressed safety and quality of pediatric emergency care, such as medication safety, guidelines to reduce radiation exposure that are age and size specific, and enhancing patient- and family-centered care.5,8,14  The recommendations also called for actively engaging patients and families in safety at all points of care, use of shared decision-making, and addressing issues of ethnic culture, literacy, and language by using trained language interpreter services rather than bilingual relatives.15 

In a study by Gausche-Hill et al, hospital ED leaders in all US states and territories were asked to complete a comprehensive web-based assessment of their readiness to care for children. The response rate was 83% and represented more than 4000 EDs. Therefore, the data reveal a snapshot of the nation’s readiness to provide care to children in the ED as well as providing information on gaps in readiness at the state and national levels. One example of a potential safety concern was that a process to ensure that weights are measured and recorded in kilograms only was lacking in 32.3% of EDs completing the assessment.16  The data also revealed that only 45.1% of ED respondents reported having a quality improvement plan addressing the specific needs of children. Of those, 58.3% identified specific quality indicators for children; 88.1% collected and evaluated data, such as transfer, deaths, and return visits; 78.9% had a plan for addressing variances in care, such as the provision of education to staff; and 73.5% had evaluation and reevaluation processes for outcome-based measures, such as the relief of pain.16 

Although much progress has been made for health care systems and hospitals’ leadership in improving pediatric readiness across communities, there remains a significant opportunity for further progress at the state and national levels. In a study by Shaw et al, a total of 1747 staff members (49%) responded to the survey on the climate of safety at 21 EDs. Of interest, there was a wide range (28% to 82%) in the proportion reporting a positive safety climate, and the rating was higher for physicians than those of nursing staff. Characteristics associated with an improved climate of safety were a lack of ED overcrowding, a sick call back-up plan for physicians, and the presence of an ED safety committee.17  Leadership’s commitment to ensuring that the ED is “pediatric ready” is essential to safe care of pediatric patients.

The main factors influencing safety culture in the ED are human, managerial, and organizational and environmental factors.18,19 

Patient- and Family-Centered Care

Providing safe care for pediatric patients in the ED is a shared responsibility between the patient (adolescent), the family, and health care personnel. Acknowledging the family’s role in the health of the patient is 1 of the core principles of patient- and family-centered care (PFCC). The health care team should engage in collaborative negotiation with patients and families to understand their priorities to be able to successfully achieve health goals.

It is critical to be inclusive of all types of families, including families with same or opposite sex married or unmarried partners, step-families, single-parent families, adoptive families, foster families, and families in which children are raised by their grandparents or other relatives. A technical report published by the AAP describes a number of important aspects of family-centered care in pediatric emergency care, including family presence, cultural sensitivity, communication, shared decision-making, coordination with the medical home, and discharge planning and instructions.7 

A qualitative study involving focus groups with parents who accompanied their child to an ED identified dimensions of PFCC important to parents. The 8 dimensions included: (1) emotional support; (2) coordination; (3) elicit and respect preferences and involve the patient and family in care decisions; (4) timely and attentive care; (5) information, communication, and education; (6) pain management; (7) safe and child-focused environment; and (8) continuity and transition. These findings provide a framework for the development of such a measure needed to improve the quality of PFCC in the ED.20 

PFCC contributes to safety in several ways. Despite the fact that the pediatric volume might not be sufficient in some general EDs to require a separate section, attention to the physical, emotional, and distinct medical needs of children is warranted for safer care. In a busy ED with critical patients, there is a need to access electrical plugs and to have containers for sharps readily available. It is important to mitigate the potential for injury by using new plugs with safety features and to keep sharp containers out of children’s reach. For children with special health care needs (autism spectrum disorder, sensory processing disorder, intellectual disabilities, nonverbal cerebral palsy, and deafness), an unexpected visit to the ED can be an overwhelming experience that creates intensifying behaviors and possibly an unsafe clinical interaction for the child and the medical team. The ED is a very stimulating environment with lights, noises, and many people, and some children with autism spectrum disorder, sensory processing disorder, and other special needs perceive stimuli at much different levels than neurotypical patients. Overstimulation in the ED can be minimized by having quiet or private rooms, especially in newly designed EDs, and providing noise-blocking headphones. Measures to keep headphones clean and secured for patient use are necessary.

In addition, adolescent patients value all aspects of privacy. Improving the care of adolescent patients requires clinicians to address not only informational but also psychological, social, and physical privacy of their patients. Confidentiality in the ED setting is also critical for the entire family.

The lack of an existing relationship with a given family and the acuity of the situation may make establishing a partnership for PFCC more difficult in the ED. Situations complicating this effort include pediatric patients arriving to the ED unaccompanied by a parent via ambulance from school or camp. Language and cultural barriers or inability to communicate with an uncooperative or nonverbal child further supports the need for PFCC to promote effective communication and safe care. The presence and expertise of a certified child life specialist in the ED that focuses on promoting effective coping skills in children during procedures like routine intravenous line insertion, wound repair, and other invasive and painful procedures can positively affect the experience for the child and caregiver and improve satisfaction with the ED visit. It also helps to decrease emotional distress in children during procedures.2123 

The use of virtual reality, internet technology, and electronic and digital devices as an effective means of distraction can reduce perception of pain. Distraction strategies are highly effective in reducing reported and observed pain and distress in children in the ED. Reducing the child’s distress and gaining cooperation lead to requiring fewer staff, facilitating safe and effective accomplishment of the medical procedure, decreasing parent anxiety, and increasing parent satisfaction.22 

PFCC also supports family presence during procedures and resuscitation, promotes acceptance by the patient and family of resuscitation decisions, and does not interfere with care or increase risk for litigation. Family presence during resuscitation can also provide the ED team with pertinent information that might be critical for making the correct diagnosis and provide an appropriate treatment plan. Establishing a clear policy and procedure for family presence, supported by all levels of the hospital staff, including other subspecialties, might decrease family and staff anxiety when procedures and resuscitations are required.7,24,25 

PFCC also encourages timely communication between the ED and the medical home, including access to electronic health records, which can facilitate understanding of the medical history and other vital sources of pertinent information regarding the patient, which help ED clinicians to provide quality and safe care. The Institute for Patient- and Family-Centered Care has many relevant resources, including a self-assessment inventory specific to the ED.26 

In addition, PFCC is especially important for safe care in the ED for children and youth with special health care needs, such as children with intellectual disabilities, nonverbal cerebral palsy, and deafness. Specific components of dignity and respect (such as listening to families), participation, collaboration, and information are essential to enhance the family experience and patient safety. Other factors valued by parents included child-oriented resources, supports for families, and environmental resources (eg, conducive and welcoming waiting room design and wait-time strategies).27 

Of importance, patients who become agitated or violent because of overstimulation, fear (eg, patients with autism spectrum disorder or sensory processing disorder), or other underlying medical or behavioral disorders can be a flight risk or risk of harm to other patients and the medical team. Safety measures can minimize the risk of harm to patients and staff. These measures include staff training in crisis intervention and safe de-escalation techniques; use of available safety resources, including hospital security; and checking the room, patient, and visitors for potentially dangerous items.

Communication

Cultural Competence, Cultural Humility

With the growing diversity in patient populations, especially children, across the United States, there is an increased risk for missed care opportunities and safety events. Explicit and implicit biases of health professionals can influence how they process information, which can affect diagnosis and treatment decisions and consequently lead to errors and health inequities.28  The fast pace and stressors in the ED environment can lead to cognitive shortcuts and greater use of stereotypes, which may exacerbate implicit biases in health care settings.28 

Several recent studies in pediatric EDs have demonstrated racial and/or ethnic disparities in many aspects of emergency care, such as analgesic management for children presenting with acute abdominal pain, appendicitis, and fractures2931 ; imaging,32  and antibiotic prescriptions in viral infections.33 

In a study by Johnson et al, analysis of data from the National Hospital Ambulatory Medical Care Survey regarding 2298 visits by patients 21 years or younger who presented to EDs with abdominal pain was conducted to determine whether race and ethnicity-based differences existed in the management of such patients. Authors adjusted for confounders in the analysis, including clinical, system-level, and socioeconomic factors and found race and ethnicity-based differences in that non-Hispanic Black patients were less likely to receive any analgesic or a narcotic analgesic (even for severe pain) than non-Hispanic white patients and were more likely to have prolonged length of stay.29 

Goyal et al conducted a retrospective cross-sectional study of children younger than 18 years with long-bone fractures using the Pediatric Emergency Care Applied Research Network Registry to measure the association between patient race and ethnicity and likelihood to receive analgesics or opioid analgesics and to achieve pain reduction.31  Authors found that non-Hispanic Black and Hispanic pediatric patients were more likely to receive analgesics and achieve a ≥2-point reduction in pain, but they were less likely to receive opioids and achieve optimal pain reduction.31 

A large multicenter cross-sectional study of more than 13 million pediatric ED visits to 44 children’s hospitals demonstrated that non-Hispanic Black and Hispanic patients were less likely to undergo diagnostic imaging than were non-Hispanic white nonhospitalized patients across all insurances. The largest imaging differences were for conditions related to the male reproductive system, eye, and digestive conditions.32  There are many contributing factors, such as parent and guardian preferences, clinician biases, and structural factors. The differences in imaging could be attributable to underuse of imaging in non-Hispanic Black and Hispanic children, or alternatively, overuse in non-Hispanic white children, both of which can contribute to unsafe care. Overuse may expose children to unnecessary risks associated with imaging, and underuse may result in misdiagnoses, delay in diagnosis, and potentially worse clinical outcomes. Therefore, future work should target factors that contribute to enhancing the quality of care delivered and health outcomes for all children.32 

A recent systematic review demonstrated a significant inverse relationship between the level of implicit bias and quality of care.34  Therefore, efforts to target implicit bias training and diversifying the ED workforce have the potential to close some of the gaps in heath disparities.

Cultural competency and humility are crucial to the delivery of optimal medical care. Overcoming cultural barriers is especially important in the ED setting because patients might use the ED as their first choice for health care. Education in health equity can improve clinicians’ cultural competency, humility, and awareness of their own implicit bias in pediatric ED settings.35 

Language Barriers

As our population becomes more diverse ethnically, racially, and linguistically, the challenge of providing safe and effective care becomes more evident. According to a report from the Agency for Healthcare Research and Quality, approximately 57 million people (20% of the US population) speak a language other than English at home, and approximately 25 million (8.6% of the United States population) are defined as having limited English proficiency.36  Language and cultural barriers have a great impact on health care delivery and patient safety because of higher rates of medical errors and worse clinical outcomes.3743  In addition, language barriers may influence the evidence-based guideline management of children in the ED, which might not align with optimal and safe care. For an example, in a study by Zamor et al, of children presenting to the ED with acute bronchiolitis, children of non–English-speaking families were more likely to receive low-value testing (eg, chest radiography, laboratory tests) compared with English-speaking families.44  Another study suggested that patients with limited English proficiency are more likely to return to the ED for admission than English-speaking patients.43 

Addressing language barriers involves providing professional language services and interpreters via phone or video 24/7, which is critical to provide safe care. Teleinterpreter services, including sign language, can also be used when needed. These services are used to obtain the correct information from patients and families as well as to explain and answer any questions patients might have regarding workup, procedures, and/or disposition.

When interpreters are not used to communicate with patients, the risk of adverse safety events increases.45  Clinicians with basic or intermediate foreign language skills often attempt to “make do” or “get by” without the use of a qualified interpreter. Clinicians’ assumptions that patients understand the information exchanged on the basis of nonverbal clues, such as nodding or smiling, is a major factor contributing to errors.45  Moreover, the use of family members and friends as interpreters is tempting, but the ability to accurately translate medical information is a skill that can be acquired only through training.45  Other recommendations in addition to hospital interpreters could include teleinterpreter services and include sign language.

Errors in Diagnosis in Pediatric Emergency Medicine

Errors in diagnosis can lead to inappropriate treatment, which can lead to patient harm. Diagnostic decision-making, a highly complex cognitive process, involves rapid information gathering and synthesis from history, physical examination, and laboratory or radiographic investigations. The diagnostic process is made under conditions of uncertainty, particularly in the ED setting, and thus, is highly susceptible to errors.46  Indeed, diagnostic errors are increasingly recognized as a major safety health concern. It is estimated that diagnostic errors occur as often as 1 in every 10 diagnoses, and such errors cause harm for 1 in every 100 ambulatory encounters.47 

Diagnostic errors can result from breakdowns in the diagnostic process at any and/or all of the process’s domains. In addition, many factors contribute to diagnostic processes failures. Patient factors include language barriers, lower health literacy, and altered mentation. Clinician factors include overconfidence, cognitive biases, inadequate training, loss of skills or competencies, and drug use. Systems factors include, but are not limited to, lack of available resources and poorly designed electronic health systems. There are many safety concerns when clinicians in the ED might not have access to medical records of patients, particularly those with complex health conditions, to make clinical decision about care. Access to emergency information could be in different forms, such as electronic format, web-based, and paper-based forms. Access to emergency information can lead to more optimal care and improvement in patient safety. This includes a decrease in medical errors, reduced morbidity and mortality attributable to improved medical decision making, and more appropriate and timely delivery of therapeutic interventions.

In the diagnostic processes, information is processed via 2 systems, including pattern recognition and analytic thinking. Experts switch between the 2 processes but spend the bulk of their time in pattern recognition system.48  Pattern recognition allows clinicians to think more efficiently about common diagnoses and make rapid decisions, which is particularly salient in ED settings but places clinicians at risk for cognitive biases.49  Some common cognitive biases that can lead to diagnostic error are included in Table 1. Finally, there is an increased recognition of the impact of the system—ie, the context of care, the influence of the diagnostic team members, and the socioeconomic system (disparities attributable to insurance, race, language barriers, social determinants of health) in which the patient-provider interaction occurs that predisposes to diagnostic errors.47 

TABLE 1

Definitions of Common Cognitive Biases

Cognitive BiasDefinition
Anchoring bias or diagnostic momentum Too much wt is assigned to the earliest or most salient features of a patient’s history or test results, and other evidence to the contrary is ignored. Diagnosis momentum: once diagnostic labels are attached to patients they tend to become stickier and stickier. Through intermediaries, (patients, paramedics, nurses, physicians) what might have started as a possibility gathers increasing momentum until it becomes definite and all other possibilities are excluded. An example of diagnostic momentum is: triage cueing: when diagnostic decisions are influenced by the original triage category a patient is placed in, such as when the triage nurse diagnosed the patient as “not sick,” therefore the patient must not be sick. There are many forms of triage, from patients self-triaging to different levels of care, to the referrals you make out of the ED that cue your consultants based on your assessment. 
Premature closure or satisfaction Once a clinician arrives at a plausible diagnosis, the clinician accepts it as the best diagnosis and stops asking questions to seek an alternative diagnosis, even if a comprehensive history or workup is not yet complete. Satisfaction: the tendency to stop searching once you have found something (this is the reason we miss the second fracture on x-ray once we identify the first, or identifying a coingestion once we have identified the first) 
Confirmation bias Once a clinician arrives at a diagnosis, all future evidence aligning with that diagnosis is considered confirmation of its accuracy, whereas any contrary evidence is subconsciously ignored. 
Overconfidence Clinicians’ confidence in their diagnosis remains constant regardless of their accuracy. 
Halo effect It is the tendency for an initial impression of a person to influence what we think of them overall. 
Availability bias The disposition to judge things as being more likely, or frequently occurring, if they readily come to mind. Thus, recent experience with a disease might inflate the likelihood of its being diagnosed. Conversely, if a disease has not been seen for a long time (is less available), it might be underdiagnosed. 
Hindsight bias Knowing the outcome might profoundly influence perception of past events and prevent a realistic appraisal of what actually occurred. In the context of diagnostic error, it may compromise learning through either an underestimation (illusion of failure) or overestimation (illusion of control) of the decision maker’s abilities. 
Perception bias The tendency to believe one thing about a group of people based on stereotype and assumptions, making it impossible to be objective about individuals. 
Ascertainment bias This is a term used in research or Evidence Based Medicine, but here it means the following: When your thinking is shaped by prior expectations. In other words, you see what you expect to see. This is the umbrella category that contains stereotyping and gender bias. For example, a teenage patient with past drug use is found unconscious and it is assumed that they have overdosed, when in fact they have severe hypoglycemia. 
Cognitive BiasDefinition
Anchoring bias or diagnostic momentum Too much wt is assigned to the earliest or most salient features of a patient’s history or test results, and other evidence to the contrary is ignored. Diagnosis momentum: once diagnostic labels are attached to patients they tend to become stickier and stickier. Through intermediaries, (patients, paramedics, nurses, physicians) what might have started as a possibility gathers increasing momentum until it becomes definite and all other possibilities are excluded. An example of diagnostic momentum is: triage cueing: when diagnostic decisions are influenced by the original triage category a patient is placed in, such as when the triage nurse diagnosed the patient as “not sick,” therefore the patient must not be sick. There are many forms of triage, from patients self-triaging to different levels of care, to the referrals you make out of the ED that cue your consultants based on your assessment. 
Premature closure or satisfaction Once a clinician arrives at a plausible diagnosis, the clinician accepts it as the best diagnosis and stops asking questions to seek an alternative diagnosis, even if a comprehensive history or workup is not yet complete. Satisfaction: the tendency to stop searching once you have found something (this is the reason we miss the second fracture on x-ray once we identify the first, or identifying a coingestion once we have identified the first) 
Confirmation bias Once a clinician arrives at a diagnosis, all future evidence aligning with that diagnosis is considered confirmation of its accuracy, whereas any contrary evidence is subconsciously ignored. 
Overconfidence Clinicians’ confidence in their diagnosis remains constant regardless of their accuracy. 
Halo effect It is the tendency for an initial impression of a person to influence what we think of them overall. 
Availability bias The disposition to judge things as being more likely, or frequently occurring, if they readily come to mind. Thus, recent experience with a disease might inflate the likelihood of its being diagnosed. Conversely, if a disease has not been seen for a long time (is less available), it might be underdiagnosed. 
Hindsight bias Knowing the outcome might profoundly influence perception of past events and prevent a realistic appraisal of what actually occurred. In the context of diagnostic error, it may compromise learning through either an underestimation (illusion of failure) or overestimation (illusion of control) of the decision maker’s abilities. 
Perception bias The tendency to believe one thing about a group of people based on stereotype and assumptions, making it impossible to be objective about individuals. 
Ascertainment bias This is a term used in research or Evidence Based Medicine, but here it means the following: When your thinking is shaped by prior expectations. In other words, you see what you expect to see. This is the umbrella category that contains stereotyping and gender bias. For example, a teenage patient with past drug use is found unconscious and it is assumed that they have overdosed, when in fact they have severe hypoglycemia. 

Investigators have begun systematically addressing the issue of diagnostic errors in the pediatric population5053  and in the pediatric emergency care setting.5458  In a cohort study of patients in whom appendicitis was diagnosed, appendicitis was initially missed in 6.0% of adults and 4.4% of children in ED visits. Population-based estimates of the rates of potentially missed appendicitis reveal opportunities for improvement and identify factors that may mitigate the risk of a missed diagnosis.55 

In a study by Sundberg et al, authors developed and applied a computerized tool to identify discordance between ED and hospital discharge diagnoses with potential for serious consequences.56  Discordance between ED and hospital discharge diagnoses occurred in 3.1% of cases, with the most common discordant diagnoses being Kawasaki disease and pancreatitis. Identifying such discordance may be valuable for improving ED diagnostic accuracy. On the other hand, final diagnosis might not be made in the ED, and the patient is admitted for further workup to make the diagnosis.

Shift Work, Burnout, and 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.5961  Burnout has led many physicians to consider reducing workload, retiring early, quitting, and even suicide.5962  Clinicians’ mental health is also often affected by burnout.61 

When measuring care quality in terms of patient safety, it is important to consider factors related to medical errors. These factors, which include diagnostic errors, incorrect medication orders, delayed care, and incorrect documentation, often have their roots in burnout.61  In a systematic review, authors found that poor well-being and moderate to high levels of burnout among staff are associated with poor patient safety outcomes, such as medical errors. Therefore, health care organizations might consider investing in improving employees’ mental health and work environments when planning interventions.63  Caring for the mental health and wellness of ED personnel may become more critical during disasters, such as during the coronavirus disease 2019 (COVID-19) pandemic because of the stressful work circumstances (lack of inpatient bed availability because of nursing shortage, leading to increase in ED on-boarding coupled with shortage of ED personnel, causing increase in their workload beyond capacity). In addition, there are concerns whether the medical profession will be able to attract sufficient numbers of nurses to care for populations into the future. Therefore, governments and health policy makers need to invest in the wellness of health care professionals, especially nursing, to ensure a healthy population.64,65 

The 24-hour operation of the ED has created the need for shift work.66  When clinicians violate the normal circadian rhythm, this inevitably leads to sleep deprivation and chronic fatigue. In fact, “off hour” shift work including evenings, nights, weekends, and holidays, as well as changing shift assignments from day to night, has been associated with premature burnout as well as poor overall physical, cognitive, and mental health.63,6669  Minimization of the short-term negative effects of a shifting sleep schedule can be accomplished with behavioral interventions such as light therapy, keeping a consistent shift, moderate caffeine consumption, and scheduled naps. Also, many of the risks of shift work of all ED staff are associated with metabolic syndrome and obesity. Therefore, keeping a healthy weight, exercising regularly, and adopting healthy eating habits might decrease such risks.

Psychological Safety and Reporting Close Calls

As part of the HRO, through the establishment of a reporting culture, everyone is empowered to identify and share patient care issues so that teams can take immediate action. The specific elements of psychological safety entail the following 4 attributes: (1) anyone can ask questions without looking stupid; (2) anyone can ask for feedback without looking incompetent; (3) anyone can be respectfully critical without appearing negative; and (4) anyone can suggest innovative ideas without being perceived as disruptive. An environment of psychological safety allows for appropriate communication reporting.70 

Incident reporting can increase patient safety, and a proactive mindset can help contain and prevent errors. Therefore, patient safety can be enhanced using reports from front-line staff of close calls and unsafe conditions to identify latent safety events. In transparent organizations, it is clear how the entities make decisions and track performance, and they have the courage to display their work openly.

In a 1 year observational study of near-miss events and unsafe conditions among hospitals in the Pediatric Emergency Care Applied Research Network, Ruddy et al found that medications and process-related issues were important causes.71  Human factor issues were highly reported, and noncompliance with established procedures, calculation issues, communications (ie, handoffs), and clinical judgment were also reported. Such reporting is vital to continue to improve systems within the ED environment to ensure patient safety.

Of interest, families could be an underused source of data about errors, especially preventable adverse events. A study by Khan et al found that parents frequently reported errors and preventable adverse events, many of which were not documented anywhere in the medical record or event reporting. Of 383 parents surveyed (81% response rate), 34 parents (8.9%) reported 37 safety incidents. Two thirds of these errors were determined to be medical errors on physician review, with 30% of medical errors causing harm (ie, were preventable adverse events).72 

Of importance, joint review and auditing of “close calls” among ED physicians and nursing staff might help in creating “just culture.” When the culture of an organization is just, it is expected that fair treatment will generate a sense of trust in the medical team. Perceptions of unfair treatment and blame suggest a possible reluctance among clinicians to report, or worse, to believe they should hide events. Therefore, open communication is critical to reporting from close calls.73  In addition, continuous learning requires feedback loops to provide data back into the various reporting systems to share information and generate insights to prompt action and learning.

ED Crowding and Patient Safety

ED crowding occurs when the need for emergency services exceeds the available resources in the ED and is detrimental to both public health and patient care quality and safety.74,75  The number of ED visits in the United States has shown continued growth, with an estimated 139 million ED visits in 2017, and 28 million of those ED visits were for children younger than 15 years.76  ED overcrowding occurs when there is a mismatch between the rising numbers of ED patients and availability of ED capacity or the increase in the ED on-boarding because of lack of inpatient bed or staff availability, as witnessed during the COVID-19 pandemic.

ED crowding threatens pediatric patient safety and poses an increased risk of medical errors.77  Studies have shown that crowding is associated with delays in antibiotic administration in febrile neonates,78  delays in analgesic administration in pediatric patients with sickle cell pain crisis,79  decreased timeliness and effectiveness of care for children with acute asthma exacerbation,80,81  and decreased timeliness and effectiveness of analgesia administration to children with fracture-associated pain.82  ED crowding has also been shown to be associated with prolonged wait times, which can lead to patient dissatisfaction83  and an increased rate of patients leaving without being seen and delaying care.76 

Sustainable solutions to ED crowding are complex, resource-intensive, and involve input, throughput, and output factors.74,75,84  Solutions aimed at decreasing input by increasing primary care access through extended hours have helped reduce ED crowding.85,86 

ACEP and the AAP highlight that ED throughput can be improved by implementing a 5-level triage system with nurse-initiated, evidence-based, standardized pathways and order sets at the point of initial triage.8789  The use of clinical pathways has been shown to decrease variation, increase efficiency, and improve safety for pediatric patients.9092  Hospital EDs can also focus on improving the efficiency of care provided to all acuity levels through the use of fast track and split flow on presentation.92,93  Innovative ED staffing models that adapt to growing patient needs and care utilization can also help improve throughput.94  Many EDs have developed observation units to further clarify which patient truly needs hospital admission. With these observation units, many patients avoid hospital admission even after initial treatment in the ED that would have led to hospitalization. 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.95 

Increasing output through the introduction of active bed management to facilitate timely ED to inpatient bed transfer has been associated with decreased ED length of stay.96,97  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, can certainly facilitate early transfer of patients from ED to the inpatient unit. Further research, education, and collaboration are essential to developing and implementing sustainable solutions to prevent and manage ED crowding to improve patient quality and safety. Despite such efforts, boarding of admitted pediatric patients in the ED, particularly for mental and behavioral health emergencies, continue to occur because of the delay in transfer of care and limited availability of inpatient units.98  Early recognition of patients who are at high risk of harm to self or others and utilization of designated safe locations in the ED improves staff and patient safety (eg, quiet environment, safe shower facilities with no hanging cords for patient presenting with suicidal ideation or attempt). Utilizing a standardized handoff in boarded patients, who typically have their care handed off more often, is also critical in ensuring a safe and quality-driven transfer of care.

Disasters, such as the COVID-19, pandemic can create many factors that increased the frequency of emotional and behavioral health problems in children and adolescents, such as the duration of the crisis, conflicting and rapidly changing messages, need for quarantine and physical isolation, and uncertainty about the future.99  These factors were compounded with the interruption of routine health care services, school and other community supports. Black and Hispanic families have also suffered even worse mental health outcomes during the pandemic because of the increased burdens of grief, food insecurity, financial instability, and education interruption.100 

The AAP recently joined the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association to declare national state of emergency in children’s mental health. Of significance, pediatric mental health boarding may worsen during disasters such as in the COVID-19 pandemic because of the increase in frequency and severity of mental illnesses.101  In addition, there is a significant increase in length of stay (LOS) for mental health ED visits with great disparities for people of Hispanic ethnicity, which was associated with an almost threefold odds of LOS >12 hours. This finding could suggest worsening and inequitable access to definitive pediatric mental health care.102 

Advocacy for systematic health care changes beyond the ED are necessary to increase access to early mental health illness identification and intervention, integrate mental health into pediatric primary care and in schools with appropriate increase insurance coverage and payment, and strengthen the child and adolescent mental health workforce. In addition, in a recent study by Das et al, authors found that increased continuity of mental health care at community health centers corresponded with a reduction in racial disparities in youth psychiatric ED visits.103 

In addition, expansion of telehealth mental health care consults to be available to the ED has the potential to assist with safety planning and postdischarge mental health outreach, enabling ED personnel to provide timely evidence-based mental health treatments, and might help in reducing the burden for pediatric centers and pediatric psychiatric units.104 

Teamwork and Team Training

Highly trained individuals with different roles and responsibilities acting in the best interest of the pediatric patient are required to provide safe emergency care. Lack of situational awareness and failure to recognize barriers to communication among disciplines can lead to errors. Originally developed by the aviation industry, recognition of the need for teamwork training in health care has led to the application of teamwork principles. Although there is no single standardized program for teamwork training, it is recognized that all share similar key concepts.105107  Training that teaches team members to crosscheck each other’s actions using easy-to-remember acronyms and mnemonics like those identified in the Children’s Hospital’s Solutions for Patient Safety-Zero Harm program decrease the possibility of errors.107 

Team training creates a plan for review of errors that is nonjudgmental and provides feedback related to system errors as well as individual drift. ED team training via simulation enhances classroom education with specific scenarios to facilitate critical thinking skills, team interaction, and communication. Multidisciplinary teams benefit from preevent briefing, huddles, and postevent debriefing to help identify opportunities for improvement. Simulation of team interaction can be an effective quality assurance tool for improving patient safety.107  In a study by Patterson et al, the implementation of a multidisciplinary, simulation-based curriculum emphasizing teamwork and communication in a pediatric ED with a preintervention baseline of 2 to 3 patient safety events per year has resulted in more than 1000 days without a patient safety event.108  Therefore, 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 for all team members to complete the training.

Interprofessional education is fundamental for improved care coordination and enhanced patient safety. Team training can be effectively embedded in physician, nursing, and emergency medical service (EMS) training programs. The Agency for Healthcare Research and Quality provides information on several team-training programs with documented success in improving communication and teamwork, which is critical in emergency care settings.109 

In addition, incorporation of a cultural broker, when available, who is the mediator between the traditional health beliefs and practices of a patient’s culture and the health care system, embraces the importance of cultural distinctions among patient groups.110  Typically, cultural brokers’ work goes beyond simply translating language and may support the team to effectively address cultural differences in their practices and subsequently promote health equity and safety.

Emergency Department Shift Huddles

Huddles support efforts to improve patient safety when they afford opportunities for heedful interactions to take place among all individuals caring for patients. Huddles create time and space for conversations geared toward care coordination. They enhance relationships and collaboration and strengthen a culture of safety, increasing in individual and collective accountability for patient safety.111113  Team huddles consisting of nursing staff, physicians, respiratory therapists, and other personnel in the ED provide the right setting for discussion among the team regarding patient safety and goals of care.114 

Safety huddles are also called daily safety briefings, daily check-ins, or daily safety calls. 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.105 

Many EDs experience communication breakdowns during shift changes. Short huddles before the start of a shift are a great way to promote teamwork by emphasizing the value of each coworker in contributing to the care to all patients and recognizing that patient safety is a shared responsibility. In addition, if time and circumstances allow, less formal “spot” meetings midshift to tackle any foreseeable concerns are encouraged.

Huddles can also improve the interprofessional and interdepartmental communication and collaboration between the ED and hospital units to improve patient flow from the ED to other units. Expedited patient admission from the ED to the appropriate unit where they can receive definitive care can potentially improve the quality and safety of patient care.115 

Handoffs in the Emergency Department

Communication errors are a contributing factor in approximately two-thirds of sentinel events,116  more than half of which involve handoff failures.117 

Patients requiring emergency care often transition among multiple care areas, including the prehospital setting, the ED, inpatient units, and medical homes. During these transitions, multiple clinicians may care for a patient, and the responsibility of the patient’s care may transfer from one clinician to another. Multiple clinicians within the ED may also care for patients across shift changes. All of these transitions of care require handoffs to exchange mission-specific information, responsibility of care, and authority for treatment and procedures.6 

It is important to recognize that miscommunication and misinformation that starts in the ED may affect a patient’s inpatient and outpatient care as well. These handoffs are a well-documented safety risk in the ED because of communication errors,118121  cognitive biases,120  and environmental factors.6  As a result, the Accreditation Council for Graduate Medical Education122  and The Joint Commission123  highlight the importance of standardized processes to reduce handoff-related errors and recommend enhancing handoff processes to improve patient safety. 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 

Unfortunately, structured handoffs occur in less than 20% of handoffs from ED to inpatient care.124,125  Numerous models have been implemented and studied to improve the quality of handoffs, including checklists,123,126  structured mnemonics,125,127,128  and handoff bundles.129,130  Examples of mnemonics include SBAR (situation, background, assessment, and recommendation),131  SOUND (synthesis, objective data, upcoming tasks, nursing input, and double check),125  ABC-SBAR (airway, breathing, circulation followed by situation, background, assessment, and recommendation),128  and I-PASS (illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by receiver).127  Quality improvement efforts designed to standardize handoffs can reduce care failures across multiple handoff types129  and reduce medical errors and preventable adverse events.130 

It is critical to actively engage patients and families in safety at all points of care, use shared decision-making, and address issues of ethnic culture, literacy, and language by using trained language interpreter services rather than bilingual relatives.7,45  In addition to improving the quality and efficiency of handoffs, some pediatric EDs have developed novel and innovative physician staffing models to allow overlapping shifts to decrease the number of handoffs that occur.132 

Special attention to identification and monitoring of patients in high-risk situations is warranted, in which key team members will visit such patients regularly to assess for change in clinical status. This situation would include handoff of 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.133 

Handoffs are a critical risk point for care failures, and further research comparing different handoff models in the ED setting are encouraged 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 ED.

It is critical for patient safety for staff to be empowered to do what is necessary for patients in a timely manner, keeping the best interest of the patient in mind. Such empowerment includes adapting to technology and developing and implementing strategies targeting providing safe and quality medical care. Staff members also need to build improvement capability and skills and receive coaching on applying these skills in their daily work.

In addition, information from front-line clinicians is critical to continue to improve any system process or strategies taken to increase patient safety.

The widespread adoption of health information technology largely stems from recognition of the important role that it plays in improving health care safety and quality. In addition, technology plays a key role in modern health care including EDs, where the electronic health record (EHR) integrates bed management, patient flow, medications, abnormal study results, charting, changes in clinical status, and disposition planning.

The implementation of computerized physician order entry (CPOE) and clinical decision support (CDS) with electronic prescribing has reduced many ordering medication errors. Most CPOE systems obviate the need for simple dose calculation.134  A study by Sethuraman et al compared prescription error rates before and after introduction of CPOE with an electronic medication alert system in a pediatric ED.135  A CPOE with an electronic medication alert system was associated with a decrease in overall prescription errors. Alerts were generated for 29.6% of prescriptions, with 45% involving drug dose range checking. Prescribers modified 20% of these dosing alerts based on dosing alerts preventing the error from reaching the patient. However, 11% of true dosing alerts for medication errors were overridden by the prescribers: of these, 11.3% resulted in medication errors, and 88.6% were false-positive alerts. Therefore, system refinements are necessary to reduce the high false-positive alert rate, which could lead to alert fatigue.135  It is important to note that CPOE systems have not fully eliminated medication errors in children, because commercial or independently developed CPOE systems may fail to address critical unique pediatric dosing requirements.134 

CDS tools are often integrated into EHRs to streamline workflows and take advantage of existing data sets. Many EDs are still facing challenges when it comes to creating user-friendly, and effective protocols for alarms, alerts, and decision-making pathways. 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.136  The authors implemented these prediction rules as decision support within the EHR to reduce computed tomography utilization. As a result, head computed tomography scan utilization rates decreased from 26.8% to 18.9%, with no increase in returns within 7 days and no significant missed diagnoses.

Other technological solutions to medical safety concerns include the use of electronic equipment (eg, programmable “smart” infusion pumps in neonates,137  barcoding to compare identification bands with medications), which has resulted in improved detection of medication calculations and administration errors.138 

Other technological advances include telehealth use in the emergency care setting. Physicians in pediatric EDs can provide consultative services via telehealth to general EDs, urgent care centers, interfacility transport teams, EMS systems, primary care provider offices, and schools. These services could be critical to provide timely and safe care in rural and critical access areas.139  In addition, telehealth might promote safe and high-quality care by minimizing preventable transfers.140  This minimization of transfers is accomplished by allowing remote specialists or critical care specialists the opportunity to more effectively assess patients in the ED during consultations.141,142 

Per a recent ACEP policy statement on telehealth, physicians are encouraged to clearly communicate treatment options, include patients and families in the decision-making process, and provide instructions on how to obtain higher-level care when needed.143  Of note, telehealth in the pediatric medical home can help eliminate access barriers, preserve the integrity of the pediatric medical home, and prevent the fragmentation of care common with standalone direct-to-consumer telehealth care providers. Medical home–based telehealth visits can also reduce ED visits for nonurgent care, thus preventing overcrowding and promoting patient safety.144 

Because of factors such as the increased availability of health care data combined with the rapid evolution of analytics techniques, artificial intelligence (AI) is integrating the health care system. Applications based on AI have many implications for patient safety. Because the ED is where many diagnostic and treatment decisions must be made quickly and effectively, the ED and triage specifically have been a major focus for data scientists familiar with AI methods. Machine learning is an AI technique that utilizes statistical models to efficiently extract patterns and “learn” from both structured and unstructured data, including free text.145  After the model is “trained” with large volumes of existing data, it can be deployed into the clinical environment to help assist with clinical decision making. These methods enable real-time predictive analytics that can help monitor vulnerable populations,146  reduce human error, increase the accuracy of diagnostic and treatment decisions, and improve patient outcomes.147  In the ED, these methods have been used specifically to identify diseases such as sepsis, appendicitis, and bronchiolitis.147  AI methods have also been used to predict the need for admission or discharge, mortality, and triage acuity levels.147  These predictive analytics techniques can also be used to guide operational decisions, which have safety implications, such as assisting with “smart” data-based scheduling of both patients and clinicians.148 

Medication errors are the most common type of medical error occurring in hospitalized patients, with rates being 3 times higher in pediatric versus adult patients.149,150  Medication error rates in pediatric EDs range from 10% to 31% and as high as 36% in rural EDs.151,152  Many factors contribute to the emergency care setting being at high risk for medication errors, particularly in children. These factors include lack of standard pediatric drug dosing and formulations, weight-based dosing, frequent interruptions, frequent transitions in care, and the lack of a pharmacist on the medical team. A summary of risk factors for medication errors during ordering, preparation, and administration and strategies for improvement is listed in Table 2. In addition, most children are cared for in EDs that treat a low number of pediatric patients, which can exacerbate such challenges.8  In a study by Alvarez et al, it was noted a high (90.6%) percentage of surveyed adult community hospitals regarding pediatric medication safety infrastructure used order sets or CPOE with pediatric weight-based dosing and 84.4% of respondents document weights only in the metric system (kilograms or grams) in the ED. On the other hand, only half had milligram-per-kilogram dosing required in the order. In addition, hospitals with greater than 300 beds had more resources and were likely to have a pediatric pharmacist than those with less than 300 beds (75% vs 44%, P ≤ .05).153 

TABLE 2

Common Medication Risks and Strategies for Improvement

Medication Error RiskStrategies for Improvement
Ordering Phase  
 Not using the appropriate wt and performing medication calculations based on pounds instead of the recognized standard of kilograms.174,175  Pediatric patients are weighed using metric units of measures (in kilograms). 
 Kilogram-only scales are recommended for obtaining weights. 
 Patient wt in kg is entered in the CPOE system before orders are entered. 
 The patient’s wt in kg or g and patient’s age are entered and verified in the pharmacy computer before entering and verifying medication orders. 
 Pharmacist recalculates the dose before preparing and dispensing medications. 
 Making inappropriate calculations including tenfold- dosing errors. Implementation of CPOE and CDS with electronic prescribing.172  
 Dose range checking software is available and enabled in the pharmacy computer. 
 Development of an override algorithm to help reduce overriding of CDS and user variability.176  
 Use of preprinted medication order forms in EDs significantly reduces medication errors and serves as a low-cost substitute for CPOE.177  
 Pharmacists recalculate the dose before preparing and dispensing medications and double-check dosing of medications during resuscitation. Ordering pediatric liquid medications in metric doses. 
 Use of length-based dosing tools when a scale is unavailable or use is not feasible. 
Dispensing and administration  
 Making errors in the medication errors in the 5 rights of medication: the right patient, the right medication, the right dose, the right time, and the right route.178  Standardizing dosage and concentrations available for a given drug, especially for high-risk or frequently used medications (resuscitation medications, vasoactive infusions, narcotics, antibiotics, and look-alike and sound-alike medications. 
 Having readily available and up-to-date medication reference materials. 
 Using premixed intravenous preparations when possible. 
 Having automated dispensing cabinets with appropriate pediatric dosage formulations. 
 Use of a distraction-free medication safety zone to decrease administration errors associated with medication preparation and interruptions.179  
 Implementation of an independent 2-provider check process for high-alert medications. 
 Preparation of intravenous and oral liquid doses includes barcode verification of ingredients. Bedside barcode scanning is used to verify patients and medications and solutions before administration. 
 Use of smart infusion pumps.180  
 Ordering pediatric liquid medications in metric doses.181  
 In code situations, read-back of dose by the medication nurse. 
Medication Error RiskStrategies for Improvement
Ordering Phase  
 Not using the appropriate wt and performing medication calculations based on pounds instead of the recognized standard of kilograms.174,175  Pediatric patients are weighed using metric units of measures (in kilograms). 
 Kilogram-only scales are recommended for obtaining weights. 
 Patient wt in kg is entered in the CPOE system before orders are entered. 
 The patient’s wt in kg or g and patient’s age are entered and verified in the pharmacy computer before entering and verifying medication orders. 
 Pharmacist recalculates the dose before preparing and dispensing medications. 
 Making inappropriate calculations including tenfold- dosing errors. Implementation of CPOE and CDS with electronic prescribing.172  
 Dose range checking software is available and enabled in the pharmacy computer. 
 Development of an override algorithm to help reduce overriding of CDS and user variability.176  
 Use of preprinted medication order forms in EDs significantly reduces medication errors and serves as a low-cost substitute for CPOE.177  
 Pharmacists recalculate the dose before preparing and dispensing medications and double-check dosing of medications during resuscitation. Ordering pediatric liquid medications in metric doses. 
 Use of length-based dosing tools when a scale is unavailable or use is not feasible. 
Dispensing and administration  
 Making errors in the medication errors in the 5 rights of medication: the right patient, the right medication, the right dose, the right time, and the right route.178  Standardizing dosage and concentrations available for a given drug, especially for high-risk or frequently used medications (resuscitation medications, vasoactive infusions, narcotics, antibiotics, and look-alike and sound-alike medications. 
 Having readily available and up-to-date medication reference materials. 
 Using premixed intravenous preparations when possible. 
 Having automated dispensing cabinets with appropriate pediatric dosage formulations. 
 Use of a distraction-free medication safety zone to decrease administration errors associated with medication preparation and interruptions.179  
 Implementation of an independent 2-provider check process for high-alert medications. 
 Preparation of intravenous and oral liquid doses includes barcode verification of ingredients. Bedside barcode scanning is used to verify patients and medications and solutions before administration. 
 Use of smart infusion pumps.180  
 Ordering pediatric liquid medications in metric doses.181  
 In code situations, read-back of dose by the medication nurse. 

CDS indicates clinical decision support; CPOE, computerized physician order entry.

A joint policy statement from AAP, ACEP, and ENA on pediatric medication safety in the ED included many strategies for improvement.8  It is essential to use weight in kilogram as the base to calculate appropriate medication dosing, rather than pounds, to avoid inappropriate calculations, including tenfold-dosing errors.154  The development of a standard pediatric formulary can reduce opportunities for error by having 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 

Many organizations including ACEP and ENA support the integration of ED pharmacists with the ED team to verify the preparation, dosing, dispensing, and reconciliation of the many medications administered in the ED as well as drug education to the heath care team and patients.155157  Having pharmacists in the ED directly, either on site or remotely (telepharmacy), has the potential to increase medication safety in the ED setting. Other strategies include the use of a distraction-free medication safety zone and implementation of an independent 2-provider check process158  for high-alert medications, as suggested by The Joint Commission and the Institute for Safe Medication Practices.159,160  Patient-identification policies, consistent with The Joint Commission’s National Patient Safety Goals, should be implemented and monitored.160 

A recent collaborative effort of the AAP and the American Academy of Pediatric Dentistry has led to the publication of guidelines that offered health professionals updated information and guidance in delivering safe sedation to children.161 

Developing policies and procedures for identifying, investigating, and disclosing adverse events related to medication errors to patients and families is important to help clinicians understand and navigate disclosure barriers. Honest and empathetic disclosure of error may reduce liability risk and litigation costs. The AAP policy statement on disclosure of adverse events in pediatrics includes clear delineation of disclosure barriers and ethical considerations in disclosure and provides practical disclosure skills.162 

Optimal pediatric disaster preparedness is built on a foundation of emergency care systems that operate reliably, effectively, and safely on a day-to-day basis. Enhancing the abilities of EDs and health care systems to meet the needs of children and their families under normal operating conditions is a sensible tactic toward improving operational resiliency for large-scale or surge events that impact children.16  EDs that make the commitment toward becoming “pediatric ready” will be better prepared to safely and effectively respond to the needs of children during disasters. EDs resourced with a physician and nurse pediatric emergency care coordinators are likely to be best prepared.16 

Children have unique physiologic, psychosocial, and psychological needs that differentiate them from adults; these differences and their care requirements may expand further during a public health emergency, especially under disaster conditions.163  Emergency and disaster readiness should consider the needs and relative vulnerabilities of the local community and the population of children served. Planning should consider children of all ages, including the special needs of pediatric patients with access and functional needs, who may have pre-existing conditions and physical, developmental, and psychosocial disabilities. Disaster planning must also take into consideration the risks and needs of children and families residing in marginalized communities.163 

There are data indicating a steady increase in the occurrence and severity of natural disasters attributed by many to climate change. Disasters aside, climate change has had a profound impact on the health of children.164  Because of their location, some communities are exposed to naturally occurring disaster threats on an annual basis, whereas in many communities disasters represent a very low-frequency event. Regardless of location, all EDs should stand ready to respond to the needs of their entire community during a crisis, including children.164 

Of note, a 2012 to 2013 national survey of ED readiness for pediatric care demonstrated that only 47% had any consideration for the needs of children in their disaster plan.16  The Emergency Medical Services for Children Improvement and Innovation Center has resources targeting important aspects of emergency care for children during disasters in a pediatric disaster preparedness toolkit based on a national multidisciplinary collaborative group.165  This toolkit includes many helpful resources, such as a checklist to help hospital administrators and leadership incorporate essential pediatric considerations into existing hospital disaster policies and resources essential to provide psychosocial support to children and families during and after disasters to ensure safety. It also provides resources to assist in the development of reunification planning elements that are inclusive, considering nonverbal children and children with disabilities and other access and functional needs, including hearing and visual impairments.

As already mentioned, readiness for the “disaster of one” on a day-to-day basis represents an important first step. Preparations for a surge event should include efforts to expand both care capacity (patient volume) and capabilities (scope of care provided) safely. Even in a children’s hospital setting, disaster care delivery will be of higher quality and safer if the institution engages in regular drills. For these exercises to be most useful, the scenario should include a number of children in excess of what might ordinarily be encountered. Hospitals will also need to consider providing levels of pediatric care not typically offered (eg, pediatric inpatients), because standard mechanisms for transfer may be disrupted and because there may be no availability of beds at the usual referral center.

There are many unique considerations in preparing to care for children safely during a disaster. Children spend an extraordinary amount of time outside their homes in school, camps, or child care programs. Affected children may, therefore, present to the ED without their parent or guardian. Infants, preschool-aged, and even some young school-aged children will be unable to fully self-identify. Hospitals must have the ability to safely track, identify, and protect unaccompanied children with a goal of accurate reunification with family or with the appropriate local agency.166,167  For children arriving with a family member, efforts must be taken to avoid the separation of the child from their family during treatment. The AAP has developed a hospital family reunification toolkit to highlight best practices for effective and safe family reunification.167 

Certain disaster agents or pathogens require the use of personal protective equipment (PPE) in the delivery of care. ED and hospital staff should regularly practice the safe donning and doffing of PPE; this practice will promote patient and staff safety. Exercises should also allow for staff to practice emergency care delivery, including procedures while wearing PPE. Some disaster agents may require decontamination at the time of arrival to the ED. Reflecting on the unique characteristics of children, decontamination may require lower water pressure and warmer water temperature to avoid injury or hypothermia as well as consideration for the decontamination of the intact family.168 

Because disasters will almost certainly continue, the ultimate goal for disaster readiness is community resiliency. Resiliency can be pursued via a whole community approach to planning, including the medical home and schools. As we are reminded by the COVID-19 pandemic and many other disasters, the largest impact on the health and well-being of children and their families has been within behavioral and mental health. It is reasonable to assume that every disaster will demonstrate a similar impact. Disaster recovery requires that plans be in place across the community and health care delivery system, including EDs, to address the increase in illness prevalence and gaps in available services.169,170 

The AAP Council on Children and Disasters (previously the Disaster Preparedness Advisory Council) has developed and periodically updates resources relating to pediatric readiness.171  The AAP offers a Pediatric and Public Health Preparedness Exercise Resource Kit that provides tools and templates to make it easier for states, communities, hospitals, or health care coalitions to conduct a pediatric tabletop exercise.172  This kit was based on implementation of an AAP and Centers for Disease Control virtual exercise. A recent study was conducted to evaluate the effectiveness of virtual tabletop exercises in improving preparedness capabilities specific to children’s needs among pediatricians and public health practitioners. The study demonstrated that participants viewed virtual tabletop exercises positively and indicated increased pediatric emergency preparedness knowledge and confidence.173  Continued work is needed to address barriers to improving local pediatric emergency preparedness for providing safe care during disasters.

In the 2000 report, “To Err is Human: Building a Safer Health System,”1  the Institute of Medicine highlighted the need to build the infrastructure for providing quality and safe medical care. Although much progress has been made to improve pediatric patient safety, there remain significant opportunities for further progress in ensuring safety of pediatric patients in emergency care settings. Pediatric patient safety requires a multidisciplinary approach across the continuum of care starting from the prehospital setting, through the ED, to inpatient settings, and beyond. Key areas for pediatric patient safety specific to emergency care that warrant attention include hospital and ED leadership commitment to safety by ensuring that EDs have the appropriate resources and capable staff to provide emergency care for children per the AAP, ACEP, and ENA joint policy on pediatric readiness in the emergency department.5  In addition, recognition of implicit and cognitive biases on safety and quality of care is critical given that the fast pace of ED heightens such biases. Other important factors including teamwork, communications, and handoffs are also important in ensuring pediatric safety in emergency care settings.

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.

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.

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.

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 Corresponding Author: Madeline M. Joseph, MD, FAAP, FACEP

Drs Joseph, Ku, Mahajan, and Saidinejad and Ms Ku 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; and all authors approved the final manuscript as submitted.

Technical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, technical reports 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 report 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.

All technical reports 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.2022-059673.

     
  • AAP

    American Academy of Pediatrics

  •  
  • ACEP

    American College of Emergency Physicians

  •  
  • AI

    artificial intelligence

  •  
  • CDS

    clinical decision support

  •  
  • CPOE

    computerized physician order entry

  •  
  • ED

    emergency department

  •  
  • EMS

    Emergency Medical Services

  •  
  • ENA

    Emergency Nurses Association

  •  
  • HRO

    high-reliability organization

  •  
  • PFCC

    patient- and family-centered care

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
Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System
.
Emergency Care for Children: Growing Pains
.
Washington, DC
:
National Academies Press
;
2007
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
Shook
JE
,
Chun
TH
,
Conners
GP
, et al;
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 of 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
Nelson
EC
,
Godfrey
MM
,
Batalden
PB
, et al
.
Clinical microsystems, part 1. The building blocks of health systems
.
Jt Comm J Qual Patient Saf
.
2008
;
34
(
7
):
367
378
11
Veazie
S
,
Peterson
K
,
Bourne
D
.
Evidence Brief: Implementation of High Reliability Organization Principles
.
Washington, DC
:
US Department of Veterans Affairs
;
2019
12
Chassin
MR
,
Loeb
JM
.
High-reliability health care: getting there from here
.
Milbank Q
.
2013
;
91
(
3
):
459
490
13
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
14
Strauss
KJ
,
Goske
MJ
.
Estimated pediatric radiation dose during CT
.
Pediatr Radiol
.
2011
;
41
(
Suppl 2
):
472
482
15
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
16
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
17
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
18
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
19
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
20
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
21
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
22
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
23
Romito
B
,
Jewell
J
,
Jackson
M
;
AAP Committee on Hospital Care; Association of Child Life Professionals
.
Child life services
.
Pediatrics
.
2021
;
147
(
1
):
e2020040261
24
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
25
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
26
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
27
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
28
Raphael
JL
,
Oyeku
SO
.
Implicit bias in pediatrics: an emerging focus in health equity research
.
Pediatrics
.
2020
;
145
(
5
):
e20200512
29
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
30
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
31
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
32
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
33
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
34
FitzGerald
C
,
Hurst
S
.
Implicit bias in healthcare professionals: a systematic review
.
BMC Med Ethics
.
2017
;
18
(
1
):
19
35
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
36
Agency for Healthcare Research and Quality
.
Chart book on patient safety
.
37
Johnstone
MJ
,
Kanitsaki
O
.
Culture, language, and patient safety: making the link
.
Int J Qual Health Care
.
2006
;
18
(
5
):
383
388
38
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
39
Goenka
PK
.
Lost in translation: impact of language barriers on children’s healthcare
.
Curr Opin Pediatr
.
2016
;
28
(
5
):
659
666
40
Al Shamsi
H
,
Almutairi
AG
,
Al Mashrafi
S
,
Al Kalbani
T
.
Implications of language barriers for healthcare: a systematic review
.
Oman Med J
.
2020
;
35
(
2
):
e122
41
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
42
Mosquera
RA
,
Samuels
C
,
Flores
G
.
Family language barriers and special-needs children
.
Pediatrics
.
2016
;
138
(
4
):
e20160321
43
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
44
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
45
Agency for Healthcare Research and Quality
.
Chapter 1: background on patient safety and LEP populations
. In:
Improving Patient Safety Systems for Patients With Limited English Proficiency
.
Rockville, MD
:
Agency for Healthcare Research and Quality
;
2012
46
Croskerry
P
,
Sinclair
D
.
Emergency medicine: a practice prone to error?
CJEM
.
2001
;
3
(
4
):
271
276
47
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
48
Kahneman
D
.
Thinking, Fast and Slow
.
New York, NY
:
Farrar, Straus and Giroux
;
2011
49
Croskerry
P
,
Singhal
G
,
Mamede
S
.
Cognitive debiasing 1: origins of bias and theory of debiasing
.
BMJ Qual Saf
.
2013
;
22
(
Suppl 2
):
ii58
ii64
50
Rinke
ML
,
Singh
H
,
Heo
M
, et al
.
Diagnostic errors in primary care pediatrics: project RedDE
.
Acad Pediatr
.
2018
;
18
(
2
):
220
227
51
Bhat
PN
,
Costello
JM
,
Aiyagari
R
, et al
.
Diagnostic errors in paediatric cardiac intensive care
.
Cardiol Young
.
2018
;
28
(
5
):
675
682
52
Cifra
CL
,
Jones
KL
,
Ascenzi
JA
, et al
.
Diagnostic errors in a PICU: insights from the Morbidity and Mortality Conference
.
Pediatr Crit Care Med
.
2015
;
16
(
5
):
468
476
53
Taylor
GA
,
Voss
SD
,
Melvin
PR
,
Graham
DA
.
Diagnostic errors in pediatric radiology
.
Pediatr Radiol
.
2011
;
41
(
3
):
327
334
54
Medford-Davis
LN
,
Singh
H
,
Mahajan
P
.
Diagnostic decision-making in the emergency department
.
Pediatr Clin North Am
.
2018
;
65
(
6
):
1097
1105
55
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
56
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
57
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
58
Mangus
CW
,
Mahajan
P
.
Common medical errors in pediatric emergency medicine
.
Clin Pediatr Emerg Med
.
2019
;
20
(
3
):
100714
59
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
60
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
61
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
62
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
63
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
64
Lake
ET
,
Narva
AM
,
Holland
S
, et al
.
Hospital nurses’ moral distress and mental health during COVID-19
.
J Adv Nurs
.
2022
;
78
(
3
):
799
809
65
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
66
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
67
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
68
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
69
Kuhn
G
.
Circadian rhythm, shift work, and emergency medicine
.
Ann Emerg Med
.
2001
;
37
(
1
):
88
98
70
Edmondson
AC
.
Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy
.
San Francisco, CA
:
Jossey-Bass Publishers
;
2012
71
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
72
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
73
Paradiso
L
,
Sweeney
N
.
Just culture: it’s more than policy
.
Nurs Manage
.
2019
;
50
(
6
):
38
45
74
American College of Emergency Physicians, Emergency Practice Committee
.
Emergency Department Crowding: High Impact Solutions
.
Irving, TX
:
American College of Emergency Physicians
;
2016
75
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
76
National Center for Health Statistics, Centers for Disease Control and Prevention
.
Ambulartory Health Care Data
.
Available at: www.cdc.gov/nchs/about/major/ahcd/ercharts.htm. Accessed June 2, 2020
77
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
78
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
79
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
80
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
81
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
82
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
83
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
84
Payne
AS
,
Brown
KM
,
Berkowitz
D
, et al
.
Improving throughput for mid-acuity patients in the pediatric emergency department
.
Pediatr Qual Saf
.
2020
;
5
(
3
):
e302
85
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
86
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
87
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
88
American College of Emergency Physicians
.
Policy on standardized protocols for optimizing emergency department care
.
89
American College of Emergency Physician
.
Policy triage scale standardization
.
90
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
91
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
92
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
93
Copeland
J
,
Gray
A
.
A daytime fast track improves throughput in a single physician coverage emergency department
.
CJEM
.
2015
;
17
(
6
):
648
655
94
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
95
American College of Emergency Physicians
.
ACEP policy on staffing models and the role of the emergency department medical director
.
96
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
97
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
98
Hoffmann
JA
,
Stack
AM
,
Monuteaux
MC
,
Levin
R
,
Lee
LK
.
Factors associated with boarding and length of stay for pediatric mental health emergency visits
.
Am J Emerg Med
.
2019
;
37
(
10
):
1829
1835
99
Guessoum
SB
,
Lachal
J
,
Radjack
R
, et al
.
Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown
.
Psychiatry Res
.
2020
;
291
:
113264
100
Krass
P
,
Doupnik
SK
.
Equity in emergency mental health care
.
Pediatrics
.
2021
;
147
(
5
):
e2020049843
101
Krass
P
,
Dalton
E
,
Doupnik
SK
,
Esposito
J
.
US pediatric emergency department visits for mental health conditions during the COVID-19 pandemic
.
JAMA Netw Open
.
2021
;
4
(
4
):
e218533
102
Nash
KA
,
Zima
BT
,
Rothenberg
C
, et al
.
Prolonged emergency department length of stay for US pediatric mental health visits (2005-2015)
.
Pediatrics
.
2021
;
147
(
5
):
e2020030692
103
Das
A
,
Singh
P
,
Bruckne
T
.
Racial disparities in pediatric psychiatric emergencies: a health systems approach
.
J Psychiatr Brain Sci
.
2020
;
5
:
e200006
104
Reliford
A
,
Adebanjo
B
.
Use of telepsychiatry in pediatric emergency room to decrease length of stay for psychiatric patients, improve resident on-call burden, and reduce factors related to physician burnout
.
Telemed J E Health
.
2019
;
25
(
9
):
828
832
105
Baker
D
,
Battles
J
,
King
H
.
New Insights About Team Training From a Decade of TeamSTEPPS
.
Rockville, MD
:
Agency for Healthcare Research and Quality, Patient Safety Network
;
2017
106
Brown
L
,
Overly
F
.
Simulation-based interprofessional team training
.
Clin Pediatr Emerg Med
.
2016
;
17
(
3
):
179
184
107
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
108
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
109
Agency for Healthcare Research and Quality, Patient Safety Network
.
Teamwork training
.
Available at: https://psnet.ahrq.gov/primers/primer/8. Accessed October 10, 2020
110
Goode
T
,
Sockalingam
S
,
Snyder
LL
, et al
;.
Bridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker Programs
.
Washington, DC
:
National Center for Cultural Competence, Georgetown University Center for Child and Human Development
;
2004
111
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
112
Brady
PW
,
Muething
S
,
Kotagal
U
, et al
.
Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events
.
Pediatrics
.
2013
;
131
(
1
):
e298e308
113
Di Vincenzo
P
.
Team huddles: a winning strategy for safety
.
Nursing
.
2017
;
47
(
7
):
59
60
114
Agency for Healthcare Research and Quality
.
Daily huddles
.
115
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
116
The Joint Commission
.
Sentinel event statistics data: root causes by event type
.
117
The Joint Commission
.
Improving hand-off communications: meeting national patient safety goal 2E
.
Jt Comm Perspect Patient Saf
.
2006
;
6
(
8
):
9
15
118
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
119
Maughan
BC
,
Lei
L
,
Cydulka
RK
.
ED handoffs: observed practices and communication errors
.
Am J Emerg Med
.
2011
;
29
(
5
):
502
511
120
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
121
Croskerry
P
.
From mindless to mindful practice--cognitive bias and clinical decision making
.
N Engl J Med
.
2013
;
368
(
26
):
2445
2448
122
Accreditation Council for Graduate Medical Education
.
ACGME common program requirements
.
123
Arora
V
,
Johnson
J
.
A model for building a standardized hand-off protocol
.
Jt Comm J Qual Patient Saf
.
2006
;
32
(
11
):
646
655
124
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
125
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
126
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
127
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
128
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
129
Bigham
MT
,
Logsdon
TR
,
Manicone
PE
, et al
.
Decreasing handoff-related care failures in children’s hospitals
.
Pediatrics
.
2014
;
134
(
2
):
e572
e579
130
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
131
Denham
CR
.
SBAR for patients
.
J Patient Saf
.
2008
;
4
(
1
):
38
48
132
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
133
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
134
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
135
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
136
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
137
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
138
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
139
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
140
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
141
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
142
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
143
American College of Emergency Physicians
.
Policy statement on telehealth
.
144
Burke
B
.
Direct-to-consumer telehealth care threatens medical home
.
AAP News
.
2015
;
36
(
2
):
15
145
Levy
M
.
Data science for healthcare: what today’s leaders must know
.
146
Palmer
J
;
Patient Safety & Quality Healthcare
.
How data analytics will improve patient care
.
147
Shafaf
N
,
Malek
H
.
Applications of machine learning approaches in emergency medicine; a review article
.
Arch Acad Emerg Med
.
2019
;
7
(
1
):
34
148
Johns Hopkins Medicine
.
Center for data science in emergency medicine
.
149
Woo
Y
,
Kim
HE
,
Chung
S
,
Park
BJ
.
Pediatric medication error reports in Korea adverse event reporting system database, 1989-2012: comparing with adult reports
.
J Korean Med Sci
.
2015
;
30
(
4
):
371
377
150
Kozer
E
,
Scolnik
D
,
Macpherson
A
, et al
.
Variables associated with medication errors in pediatric emergency medicine
.
Pediatrics
.
2002
;
110
(
4
):
737
742
151
Sard
BE
,
Walsh
KE
,
Doros
G
,
Hannon
M
,
Moschetti
W
,
Bauchner
H
.
Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department
.
Pediatrics
.
2008
;
122
(
4
):
782
787
152
Marcin
JP
,
Dharmar
M
,
Cho
M
, et al
.
Medication errors among acutely ill and injured children treated in rural emergency departments
.
Ann Emerg Med
.
2007
;
50
(
4
):
361
367
,
367.e1
367.e2
153
Alvarez
F
,
Ismail
L
,
Markowsky
A
.
Pediatric medication safety in adult community hospital settings: a glimpse into nationwide practice
.
Hosp Pediatr
.
2016
;
6
(
12
):
744
749
154
Doherty
C
,
Mc Donnell
C
.
Tenfold medication errors: 5 years’ experience at a university-affiliated pediatric hospital
.
Pediatrics
.
2012
;
129
(
5
):
916
924
155
American College of Emergency Physicians
.
Clinical pharmacist services in the emergency department
.
156
American Society of Health-System Pharmacists
.
ASHP guidelines on emergency medicine pharmacist services
.
157
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
158
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
159
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
160
The Joint Commission
.
National patient safety goals effective January 2022 for the Critical Access Hospital Program
.
161
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
162
Committee on Medical Liability and Risk Management
;
Council on Quality Improvement and Patient
.
Disclosure of adverse events in pediatrics
.
Pediatrics
.
2016
;
138
(
6
):
e20163215
163
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
164
Council on Enviro nmental Health
.
Global climate change and children’s health
.
Pediatrics
.
2015
;
136
(
5
):
992
997
165
Emergency Medical Services for Children Improvement and Innovation Center
.
Pediatric disaster preparedness toolkit
.
166
Chung
S
,
Blake
N
.
Family reunification after disasters
.
Clin Pediatr Emerg Med
.
2014
;
15
(
4
):
334
342
167
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
.
Itasca, IL
:
American Academy of Pediatrics
;
2018
168
Chung
S
,
Baum
CR
,
Nyquist
AC
;
Disaster Preparedness Advisory Council, Council on Environmental Health, Committee on Infectious Diseases
.
Policy statement: chemical-biological terrorism and its impact on children
.
Pediatrics
.
2020
;
145
(
2
):
e20193749
169
Cree
RA
,
So
M
,
Franks
J
, et al
.
Characteristics associated with presence of pediatric mental health care policies in emergency departments
.
Pediatr Emerg Care
.
2021
;
37
(
12
):
e1116
e1121
170
Schonfeld
D
,
Demaria
T
;
American Academy of Pediatrics, Disaster Preparedness Advisory Council, Committee on Psychosocial Aspects of Child and Family Health
.
Clinical report. Providing psychosocial support to children and families in the aftermath of disasters
.
Pediatrics
.
2015
;
136
(
4
):
e1120
e1130
171
Chung
S
,
Foltin
G
,
Schonfeld
DJ
, eds.
Pediatric Disaster Preparedness and Response Topical Collection Chapter 6: Pediatric Preparedness Exercises
.
Itasca, IL
:
American Academy of Pediatrics
;
2019
172
American Academy of Pediatrics
.
Pediatric tabletop exercise resource kit and other key resources for disaster preparedness
.
173
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
174
Shaw
KN
,
Lillis
KA
,
Ruddy
RM
, et al;
Pediatric Emergency Care Applied Research Network
.
Reported medication events in a paediatric emergency research network: sharing to improve patient safety
.
Emerg Med J
.
2013
;
30
(
10
):
815
819
175
Radley
DC
,
Wasserman
MR
,
Olsho
LE
,
Shoemaker
SJ
,
Spranca
MD
,
Bradshaw
B
.
Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems
.
J Am Med Inform Assoc
.
2013
;
20
(
3
):
470
476
176
Her
QL
,
Seger
DL
,
Amato
MG
, et al
.
Development of an algorithm to assess appropriateness of overriding alerts for nonformulary medications in a computerized prescriber-order-entry system
.
Am J Health Syst Pharm
.
2016
;
73
(
1
):
e34
e45
177
Larose
G
,
Bailey
B
,
Lebel
D
.
Quality of orders for medication in the resuscitation room of a pediatric emergency department
.
Pediatr Emerg Care
.
2008
;
24
(
9
):
609
614
178
Nugent
P
,
Vitale
BA
, eds.
Fundamentals of Nursing: Content Review Plus Practice Questions
.
Philadelphia, PA
:
F.A. Davis Company
;
2013
:
361
362
179
United States Pharmacopeial Convention
.
Physical Environments That Promote Safe Medication Use. Revision bulletin
.
Rockville, MD
:
The United States Pharmacopeial Convention
;
2010
180
Institute for Safe Medications and Practices
.
Smart pumps in practice: survey results reveal widespread use, but optimization is challenging
.
181
Neville
K
,
Galinkin
JL
,
Green
TP
, et al.
Committee on Drugs
.
Metric units and the preferred dosing of orally administered liquid medications
.
Pediatrics
.
2015
;
135
(
4
):
784
787