Abstract
Pediatric emergency departments (PEDs) are high-risk environments where patient injury can result from delays, unclear diagnoses, and poor communication. Quality improvement (QI) and safety culture initiatives are increasingly being used to improve outcomes, but their interaction in PEDs remains underexplored. This systematic review and meta-analysis evaluated how safety culture and QI initiatives impact clinical and functional outcomes in PEDs. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched PubMed, Cochrane, Scopus, and Web of Science through December 2024. We included 31 studies, most of which used pre/post designs; one was a randomized controlled trial. Most interventions aimed to improve care in PEDs by focusing on protocol standardization, safety checklists, simulation-based training and leadership engagement tailored to the pediatric emergency department (PED) setting. Meta-analyses showed a significant decrease in unnecessary radiation exposure (6.45%-20.55%; p<0.0001) and PED length of stay (LOS) (~25 minutes; p<0.05). Additional findings included decreased healthcare expenses, unnecessary interventions, and better patient flow. Most studies were at moderate risk of bias across the assessed domains with ROBINS-I tool. . These findings suggest that QI techniques can significantly improve the quality and efficiency of care when supported by a strong safety culture. These results show how essential it is to bring together both practical processes and cultural changes to build reliable, lasting systems that truly meet the unique needs of PEDs.