Monday, October 23, 2017

PIPSQC Spotlight

The PIPSQC Spotlight features pediatric patient safety updates from PIPSQC


The PIPSQC Blog features the latest from the front lines in pediatric patient safety


The PIPSQC Events page features upcoming conferences in pediatric patient safety

Mar 19

Written by: pipsqcblog
3/19/2017 6:30 PM  RssIcon

PIPSQC is pleased to announce, on behalf of the Making it Safer Together (MiST) paediatric patient safety collaborative, that the presentations and outcomes from the 1st MiST Symposium (February 24th, 2017) are now available online at:


The 1st MiST Symposium was attended by 72 delegates from 26 stakeholder organisations:
Email contact details for speakers
- Delegate List 


a) Presentations:

- MiST Standardisation Consensus Summit - Adam Sutherland
- Standardisation DELPHI Results

b) Workshop Outcomes:

Consensus was achieved on 16/20 medicines. Of those medicines where consensus was not achieved this was primarily in those concentrations that would be used in the neonatal care context, and it was possible to identify two potential concentrations which would facilitate a binary choice exercise. The proposed clonidine concentrations were unanimously rejected by the sedation work group as being unworkable and unsafe. An alternative range was proposed. Concerns were also raised about the risk of ten-fold error with dinoprostone. All these will be entered into a binary choice survey as follows:

The following choices will be posed:

- Morphine for preterm infants:
- Morphine for infants:
- Clonidine for all patients:
- Dinoprostone for infants:
- 40 or 100micrograms/ml
- 100 or 400micrograms/ml
- 6, 12 and 40micrograms/ml 1microgram/ml and 10microgram/ml

Three drugs were removed from the consensus framework: ketamine, sodium nitroprusside (SNP) and glyceryl trinitrate (GTN). There was a perceived lack of clinical usage (GTN), or usage was diverse and "niche" (ketamine). SNP was withdrawn as the consensus group was unable to discuss the concentration ranges. As an unlicensed medicine in the UK it was reasonable to withdraw it from the framework. This is supported methodologically as isoprenaline was withdrawn from the framework at the EAG stage for similar reasons.

c) Follow-up Survey:

It was agreed that the last three drugs, on which a consensus couldn't be reached, would be presented for feedback from all delegates. Please take the opportunity to take part in this process by completing the follow-up survey at the link below. It should not take any longer than 15 minutes to complete. Please complete the survey by midnight March 24th, 2017:


a) Presentations:

- State of the art in Scotland
- State of the art in Ireland

b) Workshop Resources:

- PEWS observation Charts
- Roland 2017: Paediatric Early Warning Systems: myths and muses
- Christofidis 2015: Less is more: the design of early-warning scoring systems affects the speed and accuracy of scoring
- Christofidis 2015: Observation chart design features affect the detection of patient deterioration: a systematic experimental evaluation
- Christofidis et al 2012: A human factors approach to observation chart design can trump health professionals' prior chart experience

c) Related Resources:

- Lambert et al 2017: Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review
- MiST - Paediatric Early Warning Systems (PEWS) resources


- Re-ACT Talks: Scores or Systems: what is a PEWS (Video)
Re-ACT Talks: Designs, Scores and Systems: Making it Easier to do the Right Thing (Video)
Safety Huddles - Leicester Children's Hospital (Video)
RCPCH - Situation Awareness for Everyone (S.A.F.E) Programme
- Re-ACT Talks: Child Deterioration: Human Factors (Video)