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Safe System Framework for Children at Risk of Deterioration

PIPSQC is pleased to share NHS Improvement and the Royal Colleges have launched the Safe System Framework - the first ever guidance to take a whole-system approach to identifying deteriorating health in children.

Children in hospital are known to suffer harm if deterioration in their condition is not recognised and treated quickly. In the worst cases, failure to recognise deterioration can lead to severe harm or death.

According to a 
Patient Safety Alert issued by NHS Improvement, research has shown that "26% of preventable deaths were related to failures in clinical monitoring," and "7% of patient safety incidents reported to the National Reporting and Learning System (NRLS) as death or severe harm were related to a failure to recognise or act on deterioration."

While many hospitals have developed programmes to improve the recognition and response to deterioration - including Early Warning Scores (EWS) - it is those organisations that have placed the EWS within a whole safe system of care that are producing better outcomes for patients.

The Safe System Framework aims to improve recognising and responding to children at risk of deterioration and focuses on six core elements:


1: Patient safety culture
2: Partnerships with patients and their families
3: Recognising deterioration
4: Responding to deterioration
5: Open and consistent learning
6: Education and training


Click here to download the resource in full (PDF, 886 KB).

For more information about the Safe System Framework, please visit:

http://www.rcpch.ac.uk/safer-system-children-risk-deterioration