Audit of Compliance with Pediatric Emergency Care Standards (September 2025)

Fatima Mohamed¹, Nada Ali¹, Asma Elhag¹, Nissreen Abdelrahman¹, Ahlam Ali¹, Fatima Mohamed¹

Abstract

 Doi : 10.5281/zenodo.17214573

Background: The baseline audit in July 2025 identified major compliance gaps in pediatric emergency care standards, including documentation (66.2%), policy adherence (52.1%), and safety practices such as consent documentation (24.4%) and visitor access control (15.6%). These deficiencies posed risks to patient safety, regulatory compliance, and accreditation readiness.

Objective: To evaluate the impact of a structured training intervention on compliance with pediatric emergency care standards through a re-audit in September 2025.

Methods: A re-audit was conducted using the same structured checklists and methodology as the baseline audit. Forty-five patient records and forty-five staff observations/interviews were reviewed across three domains: documentation, policy adherence, and infection control/safety practices. A targeted training program was implemented in August 2025, covering documentation, infection control, patient rights, incident reporting, and emergency preparedness. Compliance rates were compared between July and September 2025, with improvements expressed as absolute percentage-point changes.

Results: Documentation compliance improved from 66.2% to 85.0%, with substantial gains in patient demographics (+37.8%) and medication administration records (+24.4%). Policy compliance increased from 52.1% to ~80.0%, with dramatic improvements in consent and patient rights (+57.8%), emergency preparedness (+46.7%), and visitor access control (+48.8%). Observational practices rose from 67.3% to ~90.0%, with notable increases in patient identification (+28.9%) and bedside documentation (+28.9%).

Conclusion: The re-audit demonstrated significant improvements in pediatric emergency care compliance within two months of targeted training. While overall compliance approached 85–95% across most domains, residual gaps persisted in adverse event reporting (57.8%) and visitor access control (64.4%). Sustained monitoring, leadership support, and reinforcement of safety culture are recommended to consolidate and extend these gains.