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  • Progress in improving patient safety since the release of the 1999 Institute of Medicine (IOM) report, “To err is human” has been slower than anticipated.

  • Medical errors and adverse events are most often the result of systems flaws, not character flaws, as demonstrated by the “Swiss cheese” model of organizational accidents developed by James Reasons.

  • A culture of safety is characterized not as “blame-free,” but as a “culture of accountability” in which leaders support and encourage clinicians to make safe choices that can reduce the risk of harm to pediatric patients.

  • Medication safety is a particular concern in the pediatric emergency care setting due to the hectic environment in the emergency department (ED), a lack of standard pediatric drug dosing and formulations, the rising incidence of childhood obesity and the use of IT systems that frequently lack pediatric safety features.

  • Reduction in harm requires the active involvement of leaders who make patient safety a priority, create a strategy and structure for improvement, foster an environment of teamwork and mutual respect, and visibly celebrate successes achieved along the way in the journey to high reliability.

  • Multidisciplinary, high-performing teams are essential for safe care of children in the ED.

  • Burnout is a threat to patient safety and to the well-being of ED providers. Solutions to burnout include both organizational and individual strategies to enhance resilience.

Our understanding of “patient safety” has continued to evolve since the publication of the November 1999 Institute of Medicine (IOM) report, “To err is human,” which estimated that 44,000 to 98,000 people die from medical errors each year in this country.1 We now know that the scope of harm is even greater, and progress in improving patient safety has been slower than many had hoped.2 Though significant reduction in harm has been achieved in some specific areas, such as healthcare acquired infections, many patients and families still experience needless suffering and death due to unintended harm. Further, healthcare providers are often affected as “second victims” and left dealing with feelings of guilt and failure, sometimes leading to burnout or worse. The complexity of modern healthcare has surpassed the capability of any single provider and requires a shift from a focus on individual performance to the application of systems thinking, safety science, teamwork, and resilience.3 In this chapter, we will describe the importance of leadership, improvement science, and culture as foundational components of a comprehensive approach to providing safe and reliable care to children in the emergency department (ED) setting.


Though emergency services personnel and ED providers are hardworking and well-intended, they sometimes lack the training, tools, and resources required to provide safe, high-quality care to children in the emergency setting.

An IOM report on the US emergency care system published in 2006 revealed a lack of sufficient pediatric emergency care training and continuing education for ED staff, and ...

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