Paediatric Watch newsletters
"Paediatric Watch - Lessons from the Frontline" newsletters take learnings from a de-identified critical incident (or incidents) and highlights opportunities to improve safety for children and young people presenting to hospitals across NSW.
Read past editions below.
Myocarditis in a 7-year-old (Edition 1/2024)
January 2024
The symptoms of myocarditis may be subtle and non-specific such as fatigue, malaise and abdominal pain, making the diagnosis difficult in children.
Escalation of abnormal radiological findings (Edition 4/2023)
August 2023
This edition highlights the importance of reviewing and communicating abnormal radiological findings suggestive of a non-accidental injury to a senior doctor in a timely manner.
Asthma in adolescents (Edition 3/2023)
June 2023
This edition highlights the red flags and risk factors clinicians need to consider specific to adolescents with asthma.
Red flags for non-accidental injuries in children – Is this a child at risk? (Edition 2/2023)
March 2023
This edition highlights red flags to look out for in non-accidental injuries in children.
Near miss: 10 times adrenaline (epinephrine) dose error in anaphylaxis (Edition 1/2023)
March 2023
Errors in adrenaline dosing are common, particularly in time critical high-stress situations such as anaphylaxis. This edition focuses on lessons learnt and strategies to reduce adrenaline dosing errors.
Nasogastric Insertion: Confirmation of correct placement (Edition 3/2022)
September 2022
This edition highlights the importance of following best practice to correctly confirm placement of a nasogastric tube as per the NSW Health Guideline Infants and Children: Insertion and Confirmation of Placement of Nasogastric and Orogastric Tubes (GL2016_006).
Unrecognised oesophageal intubation (Edition 2/2022)
July 2022
This edition shares learnings from a coronial investigation following the failure to recognise oesophageal intubation in a child.
How IDEAL was your last discharge? (Edition 1/2022)
April 2022
Educating families and carers prior to discharge is a crucial step in empowering them to care for their child at home. This edition focuses on the 'Teach back' and the IDEAL discharge tool. A short video is available demonstrating how to use these tools.
Common misses and misconceptions in paediatric sepsis (Edition 2/2021)
December 2021
Timely recognition of sepsis in children continues to be a challenge in the healthcare system. This edition shares some of the common misses and misconceptions in paediatric sepsis.
Communication, escalation and intraosseous results in the deteriorating infant... (Edition 1/2020)
September 2020
This edition highlights the need to be careful when interpreting results from intraosseous samples, as they can differ significantly to results from blood samples. A webinar recording is also available on the Interpretation of intraosseous samples and Point of Care Testing.
Urgent update: Testicular torsion (Edition 4/2019)
August 2019
This edition was an urgent update from Edition 2/2018 following an increase in the number of adverse events involving missed testicular torsion. It iterates the key message that ultrasound is not a useful test to confirm or exclude testicular torsion.
Taking the confusion out of adrenaline (Edition 3/2019)
June 2019
Several factors can contribute to errors in adrenaline administration in children. This edition provides strategies to help reduce potential errors.
All that vomits is not gastroenteritis (Edition 2/2019)
April 2019
Vomiting in children is not always indicative of gastroenteritis. This edition reiterates the importance of considering differential diagnoses when a child's clinical picture does not fit the initial diagnosis.
Appendicitis: Getting it right… (Edition 1/2019)
March 2019
Appendicitis is a common paediatric surgical condition, however early identification can be difficult in children. This edition outlines some guiding principles to aid in the correct diagnosis of appendicitis in children.
Diagnostic error in the child with acute intracranial haemorrhage (Edition 6/2018)
December 2018
This edition highlights that vomiting may be the only sign of raised intracranial pressure and the importance of avoiding diagnostic anchoring.
Stop, Reflect & Review (Edition 5/2018)
October 2018
This edition highlights the importance of appropriate monitoring of patients with abnormal observations and re-assessment prior to discharge.
Not just swelling… Preventing and identifying extravasation injuries (Edition 4/2018)
August 2018
Extravasation injuries are preventable in children. This edition provides advice on how to minimise the risk of extravasation injuries and how to stage an extravasation injury should one occur.
All that wheezes is not asthma… (Edition 3/2018)
June 2018
Children presenting with a wheeze is not indicative of asthma. This edition highlights the risks associated with cognitive bias and provides strategies on how to reduce the risk of diagnostic error.
Testicular Torsion: "Twist & Shout" for advice… (Edition 2/2018)
February 2018
Diagnosis of testicular torsion can be difficult. This edition provides clinicians with tips to assist in making a timely diagnosis.
Is it the purple or the blue strip? (Edition 1/2018)
March 2018
Co-locating ketone and blood glucose strips increases the risk of the wrong one being used delaying diagnosis and appropriate treatment. This edition highlights the importance of implementing system barriers to mitigate this risk.
Deterioration in a developmentally delayed child with an acute abdomen (Edition 5/2017)
A patient with atypical behaviour and observations outside of the flags should be a 'red flag'. This edition emphasises the importance of engaging with parents and carers of these patients and the need for a low threshold for early escalation.
Matters of the Heart (Edition 4/2017)
Closed loop communication and situational awareness are important tools to help mitigate clinical risk. This edition shares insights following the delay in assessment and escalation of a baby with a cardiac arrhythmia.
SEPSIS in a heartbeat: Never ignore persistent tachycardiac (Edition 3/2017)
Recognising sepsis in children can be challenging. This edition reiterates the important message that in the presence of persistent tachycardia in children, always ask 'could this be sepsis?'
Falls: Keep them safe (Edition 2/2017)
Falls are one of the major preventable risk factors that can result in serious harm and prolong length of stay for children. This edition highlights fall prevention strategies for children and infants in hospital.
SEPSIS KILLS: Time is Life… (Edition 1/2017)
The Clinical Excellence Commission's Paediatric Sepsis Pathway is a valuable resource to assist clinicians in the timely recognition and treatment of sepsis in children. This edition focuses on the benefits of using the pathway and the importance of situational awareness.
Avoiding Oesophageal Intubation – "Gold is good" (Edition 5/2016)
Unrecognised oesophageal intubation is the most serious complication of attempted tracheal intubation. This edition focuses on how to confirm correct placement of an endo tracheal tube (ETT).
Kids Medication Safety - How independent are you? (Edition 4/2016)
In this follow up edition, further strategies are provided to help mitigate potential medication errors in paediatrics.
Kids Medication Safety involves U 2 (Edition 3/2016)
Medication errors in children are largely preventable. This edition provides some tips and strategies to help mitigate common medication errors.
Anaphylaxis – how would you react? (Edition 2/2016)
This edition focuses on the necessity of time critical intervention in children with anaphylaxis and the importance of closed loop communication to avoid medication errors.
What's the 'point' of mediation safety? (Edition 1/2016)
Medication related clinical incidents are one of the leading causes of unintended harm to children in hospitals. This edition highlights common errors in prescribing medications in children.