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 wide variation in treatment patterns for common pediatric emergencies such as stabilization, pain control, and child abuse. The report indicated that only 6% of EDs had all supplies and equipment deemed essential for managing pediatric emergencies, and many lacked pediatric-specific medication dosing strategies and guidelines.⁴

Medication safety remains a particular concern in the pediatric emergency care environment due to a number of factors, including lack of standard pediatric drug dosing and formulations, a growing number of medically complex children with multiple (and often unfamiliar) medications, a hectic environment with frequent interruptions of care providers, verbal orders, lack of medication safety experts (such as clinical pharmacists) on the ED care team, and use of information technology systems with inadequate pediatric safety features. As childhood obesity has become more common, new risks in medication dosing have been identified, including a lack of science to guide medication dosing in these patients⁵ and concerns related to imprecise dosing when using emergency aids such as length-based tools.⁶ In addition, emergency care is often characterized by numerous transitions in care and handoffs of patients from one healthcare provider to another, sometimes leading to communication breakdowns and adverse events. As we have gained an increased awareness of the risk of harm to children in emergency settings, we have learned there is no simple solution or single approach to keeping pediatric patients safe. Rather, improving patient safety requires strong leadership and role modeling, thorough knowledge of patient safety concepts and improvement science, development of a culture of safety, and a focus on data-driven improvement.⁷

A critical factor in improving patient safety in the ED is overt, visible, and continuous commitment and participation of ED leaders who understand that patient safety is best thought of as a journey and not a one time, or even short-term effort. Reduction in harm requires a multifaceted approach in which leaders work to set priorities, create a strategy and structure for improvement, and foster an environment that encourages and supports safe and reliable care.⁸ Such an environment cannot exist without the collaborative commitment of operational and clinical leaders, including ED physicians and nurses who are willing to serve as role models and lead by example.

Effective leaders set a vision with shared values and purpose, and empower the workforce (i.e., the ED clinical and support teams) by providing resources and promoting a culture of safety and continuous learning.

Setting the vision includes establishing safety priorities for the ED or Emergency Services with transparency and creating goals that are meaningful to the team. As progress is made toward the goals, it is important to celebrate success, both of the team and of individuals.

Resources required by the team to provide safe and reliable care include pediatric-specific clinical knowledge and tools, technical competence, and competencies and tools related to improvement science. More than 80% of pediatric visits to EDs are to non-children’s hospital settings, and approximately 50% of Emergency Departments in the US provide care to less than 10 children a day.⁴ Recognizing that maintenance of pediatric emergency “readiness” can be challenging in these settings, a number of professional organizations have specified needed equipment, medications and supplies, physician and nurse training and qualifications, and related services that should be in place in every ED.^9,10 In addition, ED leaders need to provide education and tools to physicians, nurses, and other members of the team so they can achieve success in driving improvement, toward a goal of high reliability.

A key responsibility of every leader, whether operational or clinical, and whether at the organization or unit level, is to create a “culture of safety” by fostering an environment of psychological safety. Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.¹¹ Hesitancy to speak up leads to increased risk for patients and for providers and inhibits the development of a learning organization. Leaders can promote psychological safety by establishing a “just culture,”¹² or a model of accountability that supports organizational fairness, through policies and practices that take into account human fallibility and the risks inherent in complex systems, when evaluating behavioral choices of physicians, employees, and staff at the time of adverse events.¹³

The delivery of safe reliable care requires an approach based on human factors and principles of high reliability. Hospital and ED leaders can design safety into their systems by developing reliable processes, which in turn require continuous learning. Continuous learning means that the individuals and teams in the learning system recognize that they can always get better and that care can be improved, so they reflect on daily activities and practices with the intention of identifying defects of every kind. Defects, or improvement opportunities, include anything that gets in the way of optimal care delivery, from equipment malfunction or a chaotic environment to clinician error or breakdowns in communication and teamwork. Once identified, defects are discussed and made visible, so that solutions can be found or improvement strategies can be developed.¹³ Fixing defects is akin to strengthening the layers of defense of the system by “plugging up” some of the holes in the Swiss cheese as described by James Reason’s model of organizational accidents,¹⁴ so the event is blocked and does not reach the patient. When leaders understand core safety concepts such as this, they can begin to transition from a punitive approach to adverse event analysis to one that focuses on the failures and resilience of systems.¹⁵ The transition to a system-based focus, rather than a focus on individual failures, however, should not be understood as shifting to a “no-blame” culture. Rather, the transition should be to a “Just Culture,” or a culture of accountability, as described by David Marx.¹² Healthcare professionals make choices every day in the workplace setting, such as the choice to wash one’s hands before and after examining patients. The Just Culture model provides a framework for managing behavioral choices, supporting and encouraging clinicians to make “safe choices” that can reduce the risk of harm to patients.

The system-based approach to patient safety must be taken by ED leaders as they strive to improve pediatric patient safety, especially in settings with a low volume of ill and injured children. Assessing equipment and medication needs, monitoring knowledge and skill-based competencies of providers, and reviewing and learning from safety events can improve pediatric readiness and, thus, improve patient safety for children in the ED.¹⁶ The ability to recognize and address systems and process failures (i.e., to find and fix defects) is a key component of a comprehensive and effective patient safety program. Applying this same rigor to the evaluation of “near miss” or “close call” events is equally important, so that safety defenses can be strengthened, and patient harm can be avoided.

A successful patient safety program requires knowledgeable senior leaders and middle managers who can provide training and support for front-line providers, so that they, in turn, can develop and implement strategies to reduce risk. An effective way for ED leaders to support front line staff in their safety improvement efforts is through patient safety rounds as described by Shaw et al.¹⁷ Patient safety rounds are regularly scheduled (monthly) meetings during which leaders walk around the unit and meet with front line staff to review patient safety data and discuss patient safety concerns. Improvement priorities can then be established, and plans to resolve issues developed and executed. The team’s activities should be monitored and reported through the performance improvement infrastructure at the unit level, then up to senior leadership, and ultimately to the governing body of the organization. A review of organizational level culture data has shown that in clinical units where a majority of caregivers had participated in walk rounds at least one time, safety climate scores were significantly higher and risk reduction, strategies were more robust, when compared with units with <60% of caregivers reporting exposure to walk rounds.¹⁸

Whatever the structure of the local patient safety program, the primary goal is to decrease harm by designing safe systems, developing and implementing risk-reduction strategies, and creating an environment that fosters a safe culture in the ED.

In 2007, Darryl Kirch delivered a President’s Address to the AAMC entitled, “Culture and the Courage to Change.”¹⁹ In his remarks, Dr. Kirch described the “traditional healthcare culture” as one characterized by hierarchy, autonomy, individual experts, and blame. He then went on to describe the modern healthcare system and the complexity of that system, which has evolved beyond the capabilities of any individual expert. Multidisciplinary expert teams are essential for improving patient safety, yet most healthcare providers complete their education with no formal training in teamwork or communication skills. Medical, nursing, pharmacy, and other healthcare-related school curricula focus on clinical information and scientific knowledge, but lack a central focus on how to effectively communicate, interact, and respond to peers, patients, and other providers. Though there have been advances in the development of interprofessional training programs at some institutions, progress has been modest.²⁰