2025/04/01 by Erin Mills, Jessica Nooney, Annmarie Bermundo +8 · 1 voice
Health Professions · Medicine · #Patient Safety and Medication Errors #Sepsis Diagnosis and Treatment #Simulation-Based Education in Healthcare
paper · pdf · doi:10.1111/1742-6723.70044
openalex publication_date 2025/04/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/29
OBJECTIVE: Paediatric resuscitations in the ED are high-pressure events in unpredictable settings. Traditionally, only cases with poor outcomes are reviewed to prevent future failures. Adopting a Safety-II mindset allows teams to reflect on both positive and negative experiences, enhancing care quality. The present study aimed to identify themes from staff feedback after paediatric resuscitations in the ED and describe system changes as a result. METHODS: A prospective quality improvement study was conducted over 31 months in a tertiary paediatric ED. Surveys were sent to clinical staff involved in paediatric resuscitations, requesting feedback on successes and suggestions for improvement. Responses were analysed using directed content analysis: initial coding using the London Protocol, a systems-focused review methodology, followed by inductive thematic analysis. Feedback was discussed in departmental Mortality and Morbidity and Quality and Safety Meetings, leading to systemic improvements. RESULTS: Eighty-nine paediatric resuscitation cases yielded 1320 specific feedback items from 256 staff members. Feedback covered all layers of the health system, with key themes focussed on the team, the environment and tasks/technology. Improvements included a transport checklist, a start-of-shift airway huddle and standardised medication preparation methods. CONCLUSIONS: Asynchronous feedback from staff involved in paediatric resuscitations identified positive and constructive themes across the health system. This feedback was successfully translated into a number of systems-focused actions to improve patient safety and care.