Bedside Procedures Coordination Failures

Harm range: Minimal temporary harm to death.

Complex minor procedures take place every day in children’s hospitals, yet teams often overlook the coordinated planning required to perform them safely.¹ Whether the event is expected or emergent, teams must coordinate supplies, communicate orders, and recognize each patient’s unique limitations. Many bedside procedures and resuscitations bring together clinicians who have never worked side by side.² Establishing team dynamics early helps prevent errors caused by poor coordination and missed communication.

Contributing factors may include:

• Failure to validate or verify medication orders at the time of verbal order or prior to administration
• Lack of understanding of the implications of a critical airway designation
• Suboptimal skill set, especially for events or procedures that do not typically occur on a certain hospital unit
• Team culture dynamics limiting an individual’s confidence to speak up, question orders, or ask for assistance
• Error in technique or process when providing rushed care in an emergency
• Issues with crowded or loud environments
• Unstructured approach lacking a defined plan for potential issues

For recent events, permanent harm resulted from coordination failures during planned airway exchanges. Temporary harm was often related to medication errors during unplanned resuscitation events that required additional procedures and monitoring.

Recommendations

• Ensure all required supplies are available at the beginning of the procedure. Consider the need for IV access, suction set-up, and different-sized airways, lines, or catheters.
• In addition to any required procedural timeout, complete a situational huddle prior to any high-risk bedside procedures to review medications, supplies, and patient-specific limitations like critical airway alerts.
  • Consider use of the Look Before you LEAPPTM acronym: Listen, Evaluate, Anticipate, Plan, and Proceed.¹
• Consider assigning a team lead to high-risk bedside procedures other than resuscitation.
• Create a process for team lead transition if the designated code team lead becomes burdened by physical tasks such as CPR.
• Place specific emphasis on repeating back the medication name, dosage, and route when taking verbal orders and again prior to administration.
• Provide pre-printed medication labels with concentration for common medications at medication dispensing locations on the unit. Include blank labels for non-preprinted medications.
• Have a clinical aid of common procedural medication dosages readily available.³
• Always press the code activation button in the room, even if multiple team members are already bedside.
• Provide interprofessional simulation opportunities for high-risk bedside events to review both process and team dynamics.

Resources

• LEAPP Video: Guidelines For Managing Invasive Pediatric Procedures

References

1. Botash, A. S., et al. (2013). BMJ Quality Improvement Reports. doi:10.1136/bmjquality.u632.w1249
2. Up to Date, Pediatric advanced life support (PALS), 2025.
3. Larose G, Levy A, Bailey B, et al. Decreasing Prescribing Errors During Pediatric Emergencies: A Randomized Simulation Trial. Pediatrics. 2017;139(3):e20163200

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