Safe System Framework

A safer system can work in partnership with families and patients, develop a patient safety culture and support ongoing learning to aim to improve recognising and responding to children at risk of deterioration.

There are multi-factorial reasons why deterioration in children is missed, including:

  • systems failure

  • not recognising and responding to the physiological changes of deterioration

  • not engaging with parents and carers to work in partnership with patients

  • insufficient training and education for healthcare professionals

A safe system framework has six core elements:

  • Patient safety culture – a large and challenging element covering many aspects that all groups are now trying to define and develop, including a commitment to overall improvement in patient safety, prioritising safety, leadership and executive accountability, and monitoring and measuring patient safety.
  • Partnerships with patients and families – while all of the core elements focus on the patient and family, this partnership is an area of increased growth and central to supporting all the others.
  • Recognising deterioration – the ability to spot physiological deviations before significant changes in care are needed or harm occurs is a fundamental working element which is central to the system.
  • Responding to deterioration – ensuring a timely and accurate response encompassing all necessary support and treatment from all those involved in the care of the patient is the vital element that is often the key change required.
  • Open and consistent learning – consideration of the system errors and individual responsibility, recording, investigating and evaluating incidents as well as best practice in order to learn and effect change will drive forward continual improvements in all elements.
  • Education and training – consistently building clinical knowledge and capability as well as patient safety and improvement methods will provide the foundation for all elements to be enhanced.

Re-ACT – Respond To Ailing Children Tool 

Re-ACT aims to improve outcomes and reduce the incidence of deterioration in the acutely ill infant, child or young person.

These films have been created for parents, and for staff supporting and empowering parents and families, with the message that the life-time of knowledge parents have of their children may enable them to spot the signs of deterioration in their child first and aims to encourage parents and families to speak up – “If you see something, say something”.

Families as Partners in Achieving Safer Care by Kath Evans, Head of Patient Experience Maternity, Newborn, Children and Young People at NHS England.

The Effect of Criticism on Parents with Sick Children by Sarah Neill, Associate Professor in Children’s Nursing at University of Northampton.

Deterioration in Children with Complex Problems by Gerri Sefton, Advanced Nurse Practitioner in Paediatric Intensive Care and Lead for PEWS at Alder Hey Children’s NHS Foundation Trust.


How to Spot the Sick Child: Seven Strategic Educational Actions by Peter Lachman, National Clinical Lead for Situation Awareness for Everyone (S.A.F.E.) at Royal College of Paediatrics and Child Health and Jane Runnacles, Consultant Paediatrician at the Royal Free London NHS Foundation Trust.

Deterioration – How to Spot the Sick Child by Ffion Davies, Consultant in Emergency Medicine at University Hospitals of Leicester NHS Trust.

Batteries, Burns and other Bombs by Rachel Rowlands, Paediatric Emergency Consultant at University Hospitals of Leicester NHS Trust.

Spotting Sepsis in the Sick Child by Jeremy Tong, Consultant Paediatric Intensivist at University Hospitals of Leicester NHS Trust.

Child Deterioration – Human Factors by Peter-Marc Fortune, Consultant Paediatric Intensivist and Associate Clinical Head at Royal Manchester Children’s Hospital.

Scores or Systems – What is a PEWS by Damian Roland, Consultant and Honorary Senior Lecturer in Paediatric Emergency Medicine, University Hospitals of Leicester NHS Trust and Leicester University.

Designs, Scores and Systems – Making It Easier To Do the Right Thing by Nikki Davey, Quality Improvement Clinic Ltd.

Early Warning System

The National Reporting and Learning System (NRLS) receives information about patient safety incidents. This evidence suggests that the greatest potential for improvement lies within the whole system of recognition and response to deterioration, and not simply the measurement of a child’s observations.

It is about an early warning system rather than an early warning score.

Spotting the Sick Child is an interactive tool to support health professionals in the assessment of the acutely sick child.

There have also been recent developments and spread of a single Paediatric Early Warning System (PEWS) in Scotland, Northern Ireland and Republic of Ireland. RCPCH are currently supporting work led by NHS England to establish a single early warning system in England and Wales as part of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme. Details of the programme can be found on the RCPCH website here.


Involving Families in Patient Safety

The Healthcare Safety Investigation Branch (HSIB) aims to improve patient safety through effective and independent investigations. The safety recommendations outlined within their reports also seek to improve healthcare systems and processes in order to reduce risk and improve safety.

NHS England have published a framework for patient involvement in safety, including involving patients in their own safety and the role of patient safety partners in organisational safety. The guidance links to medical revalidation outlined in the Good Medical Practice guide through ‘Safety & Quality’ in Domain 2 and ‘Establishing and Maintaining Partnerships with Patients’ in Domain 3, as well as the General Medical Council Handbook on effective clinical governance for the medical profession available online here.

Visit our children and young people’s engagement page to find out more about co-production and for practical tools to support improvements in patient centred care.

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