Integrating Safety Culture and Quality Improvement in Paediatric Emergency Departments: Evidence From a Systematic Review

Patient safety and quality improvement (QI) are critical pillars in paediatric emergency departments (PEDs), where high-stakes care increases vulnerability to errors. While fostering a strong safety culture is recognised as essential, its practical integration with QI initiatives is not fully understood. This systematic review aimed to synthesise evidence on how safety culture principles and QI strategies are integrated within PEDs and to assess their impact on patient safety and care quality. This review was conducted following the PRISMA 2020 guidelines. A comprehensive search of PubMed, Scopus, Web of Science, Embase, and CINAHL was performed for studies published between 2020 and 2024. Eligible studies described initiatives integrating safety culture and QI in PEDs. Data on study characteristics, interventions, outcomes, and implementation factors were extracted. The methodological quality of included studies was assessed using the Quality Improvement Minimum Quality Criteria Set (QI-MQCS). Fourteen studies were included. The integration was primarily achieved through the standardisation of clinical processes, education and training, technological integration, system-level process redesign, and structured team communication. These initiatives consistently improved outcomes, including reduced unnecessary interventions, decreased procedure times and length of stay, lower blood culture contamination rates, and enhanced patient flow. Key facilitators were iterative QI methods like plan-do-study-act (PDSA) cycles, stakeholder engagement, and clinical champions, while common barriers included workflow resistance and challenges in maintaining adherence. Quality assessment revealed strong reporting on foundational elements but a notable lack of evidence regarding long-term sustainability and the spread of interventions to other settings. The integration of safety culture principles is a powerful enabler of successful quality improvement in the PED. Effective interventions are those that address socio-cultural elements like teamwork, staff engagement, and continuous learning alongside technical process changes. Future work must prioritise demonstrating the long-term sustainability and broader disseminability of these integrated approaches to foster a pervasive culture of safety and excellence in paediatric emergency care.