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Healthcare risk assessment

Pediatric Medicine and Subspecialties Risk Assessment: Dosing, Deterioration, Handover and Consent Controls

A worked example of how a pediatric service finds, scores and controls the risks that threaten children and families, from dosing errors and infection to missed deterioration, handovers, sedation, consent and equipment failure.

Updated November 2026 8 hazards assessed Review every 6 months Highest risk: High to Medium
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Executive summary

This assessment shows how a pediatric service can find, rate and control the risks that matter most to children and families. Eight risks were chosen because they are plausible in everyday ward, emergency, clinic and imaging work. Dosing errors, missed deterioration and sedation complications carry the highest natural scores because a single lapse can cause serious harm. Each risk is scored before controls and again after existing and proposed controls. Most risks fall to Low or Medium once the additional controls are in place, but sedation keeps a high impact even though its likelihood is low. The first actions are a standard pediatric dosing check, an age specific observation chart, a single handover format and a written sedation plan. The service is a teaching example, so every score illustrates method, not a real organization or patient group.

Focus area
Pediatric medicine and subspecialty care
Setting
Hospital pediatric inpatient, emergency and outpatient subspecialty services in a healthcare setting
Method
Five by five likelihood and impact risk register

Scope

This assessment covers care of infants, children and adolescents across a general pediatric ward, an emergency area, imaging and subspecialty clinics, from admission and prescribing to discharge and follow up. It considers risks to patient safety, families, staff and records. The health system, jurisdiction, staffing model and electronic record are not specified, so they are treated as teaching assumptions. It does not cover adult care, research protocols or any individual patient.

Context

The service has an inpatient pediatric ward, an emergency area that receives children at all hours, and clinics for cardiology, endocrinology, oncology and neurology. Medicines are prescribed through an electronic record and dispensed by pharmacy, using weight based doses. Nurses monitor children with observation charts and an age adjusted early warning score. Families are partners in care, and consent or assent is sought at each step. Each risk is scored before controls to show its natural level, then again after the existing controls and the additional controls proposed here.

Objectives, assets and stakeholders

The objective is to keep children safe from avoidable harm, deliver timely and appropriate treatment, respect the rights of children and families, and keep the trust placed in the service. The assets in scope are the children in care, the medicines and equipment used to treat them, clinical records and personal information, the skills and time of staff, and the reputation of the service. Stakeholders include children, parents and guardians, nurses, doctors, pharmacists, allied health staff, the clinical governance team, regulators and commissioners. Clear roles matter: every risk has one owner role, and the clinical governance lead reviews the register each quarter and reports to the service board.

Risk matrix: before and after controls

Each cell shows hazard numbers placed by likelihood and impact. Compare the two grids to see how controls move each hazard.

Before controls

Inherent risk

Risk before controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely Likelihood 4, impact 3, score 12, high: H02 H04 Likelihood 4, impact 4, score 16, high: H01
3 Possible Likelihood 3, impact 3, score 9, medium: H07 Likelihood 3, impact 4, score 12, high: H05 H06 Likelihood 3, impact 5, score 15, high: H03
2 Unlikely Likelihood 2, impact 5, score 10, high: H08
1 Rare

After controls

Residual risk

Risk after controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely
3 Possible
2 Unlikely Likelihood 2, impact 2, score 4, low: H02 H07 Likelihood 2, impact 3, score 6, medium: H01 H04 H05 H06 Likelihood 2, impact 4, score 8, medium: H03
1 Rare Likelihood 1, impact 5, score 5, medium: H08
  • Low 1 to 4
  • Medium 5 to 9
  • High 10 to 16
  • Critical 17 to 25

Hazard register

A summary first, then the detail for each hazard.

Summary of hazards with scores before and after controls
No.HazardBeforeAfterOwner
H01 Weight based medication dosing error 16 High 6 Medium Clinical pharmacy lead
H02 Healthcare associated infection and exposure control gaps 12 High 4 Low Infection prevention and control lead
H03 Missed deterioration in an unwell child 15 High 8 Medium Ward nurse manager
H04 Handover errors between shifts and teams 12 High 6 Medium Clinical nurse educator
H05 Consent, assent and privacy breaches 12 High 6 Medium Clinical governance lead
H06 Equipment and information system failure 12 High 6 Medium Biomedical engineering lead
H07 Staffing shortfalls and gaps in subspecialty competence 9 Medium 4 Low Workforce planning manager
H08 Sedation and procedure complications in clinic and imaging 10 High 5 Medium Sedation lead clinician
H01

Weight based medication dosing error

Safety Before 16 After 6

A dose is calculated from the wrong weight, a unit is misread or a decimal point is missed, so a child receives too much or too little of a drug, which can cause serious harm. Risk is higher for high alert medicines and for infusions.

Who or what is affected: Children, families, prescribers, nurses and pharmacists

Causes

Manual calculation, a recent weight that was not updated and interruptions during busy shifts.

Consequences

Overdose or underdose, toxicity, longer stay, serious harm and a formal investigation.

Existing controls

  • Prescribing uses the electronic record with a weight field and dose range checks.
  • A second nurse checks high alert medicines before administration.

Control gaps

Weight is sometimes copied from an old record, and override reasons are not reviewed.

Additional controls

  • Prevent: Use standard pediatric dosing sheets and pharmacy verified weight based limits for each high alert drug.
  • Detect: Run a weekly audit of overridden dose alerts and doses outside the expected range.
Likelihood 4 x impact 4 before; 2 x 3 after Owner: Clinical pharmacy lead Target: Within 30 days Early warning: Override of a dose range alert for a high alert medicine.
H02

Healthcare associated infection and exposure control gaps

Safety Before 12 After 4

Hand hygiene, isolation precautions or cleaning are missed, so infections spread between children, staff and visitors, including through shared equipment, toys and devices.

Who or what is affected: Children with weak immunity, families, staff and visitors

Causes

Busy shifts, shared equipment, visitors who do not follow rules and children who shed organisms for long periods.

Consequences

Ward outbreak, transfer of sick children, delayed discharge and harm to vulnerable patients.

Existing controls

  • Alcohol hand rub is available at every bed space.
  • Isolation signs are placed on rooms for known infections.

Control gaps

Hand hygiene audits are occasional, and cleaning checks for shared toys and devices are not recorded.

Additional controls

  • Prevent: Require hand hygiene on every entry and exit of a bed space, observed monthly by a peer.
  • Respond: Start isolation within the hour of a suspected infection and inform the infection prevention team at once.
Likelihood 4 x impact 3 before; 2 x 2 after Owner: Infection prevention and control lead Target: Within 60 days Early warning: Two or more linked infections on the same ward within one week.
H03

Missed deterioration in an unwell child

Safety Before 15 After 8

Early signs of sepsis, breathing failure or dehydration are missed or not escalated because observations are delayed, scores are miscalculated or a parent's concern is dismissed.

Who or what is affected: Children, families, ward nurses and medical teams

Causes

Heavy workload, subtle early signs, unclear escalation thresholds and reliance on a single observation.

Consequences

Cardiac arrest, unplanned transfer to intensive care, lasting harm or death.

Existing controls

  • Observations use an age adjusted early warning score with set escalation levels.
  • Families are invited to call for help when they are worried.

Control gaps

Family concern is recorded but not always reviewed by a senior clinician.

Additional controls

  • Prevent: Use an age specific observation chart with automatic score calculation in the record.
  • Detect: Review each missed observation and each escalation within twenty four hours and report the findings.
  • Respond: Activate a rapid response call at the top score and page the on call pediatric registrar.
Likelihood 3 x impact 5 before; 2 x 4 after Owner: Ward nurse manager Target: Within 30 days Early warning: Observations overdue by more than one hour on a child with a raised score.
H04

Handover errors between shifts and teams

People Before 12 After 6

Key information about a child's plan, pending results, allergies or family concerns is missed or unclear during a shift change or a transfer between ward, clinic and emergency care.

Who or what is affected: Children, families, nurses, doctors and allied health staff

Causes

Time pressure, several teams involved, verbal only handovers and changes made late in a shift.

Consequences

Missed doses, delayed treatment, repeated tests and distress for families.

Existing controls

  • A standard handover tool is used at each shift change.
  • Pending results are listed on the ward board.

Control gaps

Handover audits happen only after an incident, and transfers from clinic to ward are not standardized.

Additional controls

  • Prevent: Use one structured handover format with allergies, weight and plan read back aloud.
  • Detect: Sample handovers each month and score them for completeness against the standard.
Likelihood 4 x impact 3 before; 2 x 3 after Owner: Clinical nurse educator Target: Within 45 days Early warning: Handover audit finding missing allergy or weight information.
H05

Consent, assent and privacy breaches

Legal and compliance Before 12 After 6

Treatment starts without valid consent or assent from the child and a parent or guardian, or confidential information is shared with the wrong person, posted publicly or left visible on a screen or printout.

Who or what is affected: Children, parents and guardians, clinicians and administrators

Causes

Unclear guardianship in complex families, busy consent conversations and shared screens.

Consequences

Loss of trust, legal challenge, regulator notice and distress to the child and family.

Existing controls

  • Consent forms are signed before procedures and filed in the record.
  • Staff complete annual training on confidentiality.

Control gaps

Assent is not always recorded, and screen privacy is checked only during occasional audits.

Additional controls

  • Prevent: Confirm guardianship and record the child's assent at a level suited to age before any non urgent procedure.
  • Respond: Report every privacy breach through the incident system and inform the data protection lead within one working day.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Clinical governance lead Target: Within 60 days Early warning: Consent forms with missing guardian or assent details.
H06

Equipment and information system failure

Technology and data Before 12 After 6

Infusion pumps, monitors, child sized equipment or the electronic record fail, run out of battery or lose connection, so treatment is delayed or dosing and observation data are lost.

Who or what is affected: Children, nurses, doctors and pharmacy staff

Causes

Ageing devices, low battery, network outage and equipment shared between wards.

Consequences

Delayed treatment, dosing error from paper workarounds, lost observation data and harm.

Existing controls

  • Equipment is serviced on a published schedule and checked before use.
  • Paper backup charts are kept at each ward station.

Control gaps

Downtime drills are not run, and backup charts are not reconciled into the record after recovery.

Additional controls

  • Prevent: Keep a labeled stock of pediatric sized equipment and check batteries at the start of each shift.
  • Recover: Run a downtime procedure with paper prescribing and test the backup record each quarter.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Biomedical engineering lead Target: Within 90 days Early warning: Equipment past its service date or a network outage longer than the downtime limit.
H07

Staffing shortfalls and gaps in subspecialty competence

People Before 9 After 4

Shifts are staffed below safe levels or by staff without current pediatric competence, and subspecialty cover is thin, so children are cared for by people who are not yet confident in the task.

Who or what is affected: Children, families and the staff who cover shifts

Causes

Vacancies, sickness, short notice absence and training that has lapsed.

Consequences

Fatigue, errors, missed care, low morale and staff turnover.

Existing controls

  • Rotas are checked against a minimum staffing plan each week.
  • New staff are supervised during their first shifts.

Control gaps

Competence records are kept on paper and are not checked against the rota.

Additional controls

  • Prevent: Set a minimum pediatric competence list for each role and check it before rostering.
  • Respond: Call bank staffing and the senior on call when a shift falls below the minimum.
Likelihood 3 x impact 3 before; 2 x 2 after Owner: Workforce planning manager Target: Within 60 days Early warning: Shifts filled below the minimum staffing level on two or more days in a row.
H08

Sedation and procedure complications in clinic and imaging

Safety Before 10 After 5

Sedation for scans or procedures causes breathing problems, falling oxygen levels or an allergic reaction, especially in young or medically complex children, because monitoring is incomplete or recovery is rushed.

Who or what is affected: Children, families, sedation staff and imaging staff

Causes

Unclear fasting instructions, incomplete medical history, rushed recovery and low staffing in imaging.

Consequences

Airway injury, low oxygen, cardiac arrest, transfer to intensive care and lasting harm.

Existing controls

  • A pre sedation assessment is completed and fasting times are recorded.
  • Pulse oximetry monitoring is used throughout each procedure.

Control gaps

Recovery observation time is not audited, and rescue drills are not recorded.

Additional controls

  • Prevent: Use a written sedation plan with weight based doses and a named clinician responsible throughout.
  • Detect: Review oxygen and heart rate trends after each sedated case and log any event that needs review.
  • Respond: Keep airway equipment and a trained team ready in every sedation area and rehearse emergencies each quarter.
Likelihood 2 x impact 5 before; 1 x 5 after Owner: Sedation lead clinician Target: Within 30 days Early warning: Sedated child with oxygen saturation below the agreed threshold during recovery.

Rating method and evaluation

Each risk is rated on two five point scales. Likelihood runs from 1, rare, to 5, almost certain. Impact runs from 1, minor, to 5, catastrophic, judged on physical harm, distress, time to correct, effect on treatment and damage to trust. Multiplying the two gives a score from 1 to 25 in one of four bands: Low from 1 to 4, Medium from 5 to 9, High from 10 to 16 and Critical from 17 to 25. Inherent risk is the score before any controls. Residual risk is the score after the existing and additional controls. Residual must never be higher than inherent, and where inherent is 10 or more, residual must be lower. A low likelihood is never used to lower the rating of a severe impact on a child. Anything still High needs senior clinical attention and a dated plan, anything Medium needs routine controls with a named owner, and anything Low is accepted and watched. Frontline staff, families where appropriate, and the clinical governance team should challenge the ratings, and each risk is reviewed whenever its early warning indicator reaches the threshold or after any serious incident.

Likelihood, impact and rating bands

Likelihood

  • 5 Almost certain: Expected to happen in most circumstances.
  • 4 Likely: Will probably happen in many circumstances.
  • 3 Possible: Could happen at some time.
  • 2 Unlikely: Not expected, but it could happen.
  • 1 Rare: Only in exceptional circumstances.

Impact

  • 1 Insignificant: No lasting effect. Handled within routine work.
  • 2 Minor: Small effect that is quickly corrected.
  • 3 Moderate: Noticeable effect that needs managed effort to correct.
  • 4 Major: Serious effect on people, delivery or reputation.
  • 5 Catastrophic: Severe or lasting effect that threatens the whole activity.

Bands (likelihood x impact)

  • Low (1 to 4): Accept and monitor.
  • Medium (5 to 9): Manage with routine controls.
  • High (10 to 16): Senior attention and a treatment plan.
  • Critical (17 to 25): Act first. Do not proceed until reduced.

Monitoring, escalation and review

Review this assessment every 6 months, and sooner when an indicator below reaches its threshold.

Early-warning indicators and escalation thresholds
Indicator to watchEscalate when
Overridden dose range alerts for high alert medicines in the weekly audit.Escalate to the clinical pharmacy lead when any override lacks a documented reason, and to the medical director if a dose error reaches a child.
Observations overdue by more than one hour on a child with a raised early warning score.Escalate to the ward nurse manager at once, and to the senior clinician on call if the child's score is still raised after one hour.
Handover audit results showing missing allergy or weight information.Escalate to the clinical nurse educator when more than one in ten audited handovers is incomplete, and to the ward manager for a refresher plan.
Sedated children with oxygen saturation below the agreed threshold during recovery.Escalate to the sedation lead clinician immediately, and review the case with the clinical governance lead within one week.
Equipment past its service date or a network outage longer than the downtime limit.Escalate to the biomedical engineering lead at once, and to the service manager if equipment remains out of service for a full shift.

Contingency arrangements

If a serious event occurs, such as a child harmed by a medicine error, a missed deterioration or a sedation emergency, the senior clinician on duty leads immediate care and calls the rapid response team. The ward manager secures the area, preserves records and equipment, and informs the clinical governance lead the same day. Families are told what has happened, what is being done and who to contact, honestly and promptly. The incident is reported through the formal system, and specialist review is requested for any event that causes serious harm.

Prioritized action plan

  1. Introduce a pharmacy verified weight based dosing check for high alert medicines, owner clinical pharmacy lead, within 30 days.
  2. Use an age specific observation chart with automatic scoring and a set escalation route, owner ward nurse manager, within 30 days.
  3. Write and rehearse a sedation plan with airway drills for every sedation area, owner sedation lead clinician, within 30 days.
  4. Adopt one structured handover format with allergies and weight read back aloud, owner clinical nurse educator, within 45 days.
  5. Confirm guardianship and assent before non urgent procedures and test screen privacy, owner clinical governance lead, within 60 days.

Conclusion

Safe pediatric care depends on a few steady habits: weight checked before every dose, observations that escalate without delay, a structured handover at each change, valid consent and assent recorded, and equipment and records that work when they are needed. The highest scores sit with dosing, deterioration and sedation, and each has controls that bring the residual score down. Treat the register as a living record, review it on the stated cycle, and seek specialist and licensed clinical advice for any real treatment, legal or safeguarding question.

Assumptions and limitations

Assumptions

  • The service follows a recognized clinical governance model, which is not named here.
  • Staff are licensed clinicians with pediatric training, and subspecialists cover referrals on a rota.
  • The electronic record and pharmacy system are assumed to share a formulary and alert for weight based doses.
  • Consent, assent and privacy duties are described in general terms because the jurisdiction is not specified.

Limitations

  • The scores are examples for learning and do not describe any real service, ward or child.
  • Clinical guidance changes over time, so specialist and qualified clinical review is needed before any change to practice.
  • This educational content does not replace a formal site-specific risk assessment or licensed clinical advice.

Related frameworks to study

  • Clinical governance and incident reporting cycle
  • Hierarchy of controls
  • Structured handover tools using a situation, background, assessment and recommendation format
  • Three lines model of risk ownership
  • Root cause analysis

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For Learning Reference Only: This assessment demonstrates how risk assessment principles are applied in a practical setting, providing a useful reference for learning and understanding. Actual assessments may be adapted to suit specific site conditions and circumstances.

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