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BACKGROUND: For the early recognition of deteriorating patients several Pediatric Early Warning Score (PEWS) systems have been developed with the assumption that early detection can prevent further deterioration. Although PEWS are widely being used in hospitals in the Netherlands, there is no national consensus on which score to use and how to embed the score into a PEWS system. This resulted in a substantial heterogeneity of PEWS systems, of which many are unvalidated or self-designed. The primary objective of this study was to develop a pragmatic consensus-based PEWS system that can be utilized in all Dutch hospitals (University Medical Centers, teaching hospitals, and general hospitals). METHODS: This study is an iterative mixed-methods study. The methods from the Core Outcome Measures in Effectiveness Trials (COMET) initiative were used and consisted of two Delphi rounds, two inventories set out to all Dutch hospitals and a focus group session with parents. The study was guided by five expert meetings with different stakeholders and a final consensus meeting that resulted in a core PEWS set. RESULTS: The first Delphi round was completed by 292 healthcare professionals, consisting of pediatric nurses and physicians. In the second Delphi round 217 healthcare professionals participated. Eventually, the core PEWS set was been developed comprising of the parameters work of breathing, respiratory rate, oxygen therapy, heart rate and capillary refill time, and AVPU (Alert, Verbal, Pain, and Unresponsive). In addition, risk stratification was added to the core set with standardized risk factors consisting of [1] worried signs from healthcare professionals and parents and [2] high-risk treatment, with the option to add applicable local defined risk factors. Lastly, the three categories of risk stratification were defined (standard, medium, and high risk) in combination with standardized actions of the professionals for each category. CONCLUSION: This study demonstrates a way to end a country's struggle with PEWS heterogeneity by co-designing a national Dutch PEWS system. Currently, the power of the system is being investigated in a large multi-center study in the Netherlands.

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QUALITY PROBLEM: Despite its success in other industries, process standardization in health care has been slow to gain traction or to demonstrate a positive impact on the safety of care. INTERVENTION: The High 5s project is a global patient safety initiative of the World Health Organization (WHO) to facilitate the development, implementation and evaluation of Standard Operating Protocols (SOPs) within a global learning community to achieve measurable, significant and sustainable reductions in challenging patient safety problems. GOALS: The project seeks to answer two questions: (i) Is it feasible to implement standardized health care processes in individual hospitals, among multiple hospitals within individual countries and across country boundaries? (ii) If so, what is the impact of standardization on the safety problems that the project is targeting? METHOD: The two key areas in which the High 5s project is innovative are its use of process standardization both in hospitals within a country and in multiple participating countries, and its carefully designed multi-pronged approach to evaluation. STATUS: Three SOPs-correct surgery, medication reconciliation, concentrated injectable medicines-have been developed and are being implemented and evaluated in multiple hospitals in seven participating countries. Nearly 5 years into the implementation, it is clear that this is just the beginning of what can be seen as an exercise in behavior management, asking whether health care workers can adapt their behaviors and environments to standardize care processes in widely varying hospital settings.

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OBJECTIVES: To investigate the effect of pharmacy-based medication reconciliation on the frequency of unintentional medication discrepancies in acutely admitted individuals aged 65 and older. DESIGN: Multicenter intervention study with pre-post design. SETTING: Twelve Dutch hospitals. PARTICIPANTS: One thousand five hundred forty-three individuals aged 65 and older with an acute hospital admission through the emergency department. MEASUREMENTS: The intervention consisted of the Best Possible Medication History (BPMH), based on combining information from the community pharmacy record, the information provided by a structured interview with participants about their medication use, and medication containers. In nine hospitals, pharmacy technicians obtained the BPMH, and in three hospitals, a mixed model was used (physicians or pharmacy technicians obtained the BPMH). Primary outcome measure was the proportion of participants with one or more unintentional medication discrepancies. The primary outcome measure was stratified according to type of intervention (pharmacy based vs mixed model). RESULTS: The proportion of participants with one or more unintentional medication discrepancies was reduced from 62% to 32% [odds ratio (OR) = 0.29, 95% confidence interval (CI) = 0.23-0.37]. These results remained statistically significant after adjustment for type of department and hospital (OR = 0.20, 95% CI = 0.15-0.26), and this effect remained stable for 6 months. Stratified analysis showed that no effect from the intervention was evident in the three hospitals with a mixed-model intervention, in contrast to the hospitals with a pharmacy-based intervention. The medication discrepancy types "omission" and "dosage or strength" occurred most frequently and were the main types that the intervention influenced. CONCLUSION: Pharmacy-based medication reconciliation leads to a substantial reduction in medication discrepancies in acutely admitted elderly adults.

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This article addresses Wolter De Loos' pathway into ESTSS that ended on 6th January 2004. His footsteps are still printed in the field of psychotraumatology as he showed the field how a physician was trying to integrate his working field with that of psychiatry, with a great passion for his patients. Erica M. Van der Schrieck-De Loos outlines the perspectives of her father as funding president of the ESTSS by using his Opening Address of the Fourth ESTSS Conference in 1995. This address emphasized that the mixture of righteousness and offence in warfare is ubiquitious and everlasting. The perspective of the first president's pathway has been integrated with the current vision of the author to show that the patient can be a partner of the healthcare team. A suggestion for ESTSS main objective number (8), contained within the ESTSS mission statement, is to involve patients as partners of the traumatic stress care team into accelerating traumatic stress care across Europe and beyond.