Funding for this research was provided by:
Physicians' Services Incorporated Foundation
Received: 11 February 2021
Accepted: 25 August 2021
First Online: 16 September 2021
: This research was approved by the Research Ethics Boards at the hospital where the research occurred. The reference number is #1000054740. All interview participants gave written informed consent to participate and be audiotaped. All observation participants were informed about the observation and provided the opportunity to request not to be observed.
: Not applicable
: MCoffey is the Associate Clinical Director, Children’s Hospital Solutions for Patient Safety. All other authors have no competing interests.