World Patient Safety Day, observed annually on 17 September, this year promotes the theme “Safe care for every newborn and every child”, with the slogan “Patient safety from the start!”. It is timely reminder that every young person throughout childhood deserves unwavering protection from avoidable harm. This focus on patient safety extends into adolescence and beyond through the critical inflection point when care is transferred to adult services. 

Transitional care can be described as the purposeful, planned movement of adolescent and young adult patients to with chronic conditions from team based, carer-driven paediatric services to patient-driven adult health care systems.  

Recognising the patient safety risks, in common with many units, we have cooperated with paediatric surgical colleagues to develop a systems-based approach in our formalised transitional process. This helps to provide personalised structured plans and with a format of communication and clinical review to ensure safe transfer of care at what is often a crucial time of dynamic change for patients on a personal, social, as well as medical level. 

Advances in urological paediatric surgery, as well as neonatal intensive care and anaesthesia, have hugely improved survival into adulthood of children with complex surgical reconstructions and consequent long-term care needs. Those born with conditions such as posterior urethral valves, bladder exstrophy, cloacal anomalies, and spina bifida now routinely live well into adulthood and require lifelong follow-up. The increased use of augmentation and reconstructive surgery, such as continent diversion and continent catheterisable channels such Mitrofanoff are standard. The long-term risks, such as recurrent infection, bladder stone formation, malignancy, and late surgical failure all require adult services to be aware, vigilant in surveillance, and able to manage these conditions. Renal preservation by early intervention and active management of obstructive uropathy, high pressure neurogenic bladders and vesico-ureteric reflux have improved survival, but many enter adulthood with renal function an ongoing risk, in need of ongoing careful surveillance. 

Adult services must be aware and responsive to the additional needs of patients with long histories of paediatric care. The long-term continence, sexual health and fertility should be a focus, not only of the initial paediatric surgery, but also ongoing review. The time of transfer to adult services may coincide with increase the personal importance of these issues and growing patient independence and autonomy. With the chronicity of many childhood urological conditions, patients and their families rightly expect continuity with safe handover. These complexities together with a recognition of the adolescent gap in care, a high-risk period for disengagement mean that a combined transitional arrangement is essential. 

There are many patient safety risks inherent in such transfer of care. The negative consequences of such risk being realised can be mitigated by a structured approach. The SEIPS (System Engineering Imitative for Patient Safety) framework describes how work systems (external environment, organisation, internal environment, tools and technology, tasks and persons) influence process (work done) and thus outcomes in complex socio-technical systems, such as healthcare. Awareness of the elements in this framework help to shape the mitigation strategies to each risk, building a coherent structured transitional process for patients. 

Fragmented handover of information might lead, for example, to missed surgical history details, inappropriate management or delayed detection of deterioration such as renal function. This can be mitigated by a standardised summary at a transition joint clinic between the involved services. These tools lead to a secure process for information flow with the outcome of reliable continuity of care. Other recognised risks: loss to follow-up, inadequate surveillance, medication errors can likewise be mitigated by systems of coordination, early introduction to adult services and standardised documentation and involvement of a multidisciplinary team of surgeons, nurses, other allied health professionals together with the patient, parents and carers. 

There are differences in how paediatric and adult services function. Paediatric surgery internally integrates the different specialties needed in the care of patients with congenital genitourinary and associated conditions. The same team, and often individual surgeon, may deal with urinary, bowel and mobility issues. In adult care the urologist may have to facilitate an MDT of  multiple disparate specialties. This cultural mismatch, along with possible gaps in expertise within the adult surgical team, may be addressed by gradually introducing the adult team through joint clinics. This approach helps ensure the involvement of appropriate specialties and protocols for ongoing patient management, which can lessen future anxiety and reduce the likelihood of patient disengagement. 

The sharing of information with joint assessment within a multidisciplinary team, including associated AHPs, such as psychologists, pharmacists, help to ensure security in questions of capacity, consent and safeguarding. In addition, there can be clear transfer of responsibly to prevent tasks falling between teams and thus ensuring secure governance and accountability with safe flow rather than hand-off of care. 

Our transitional clinic has been formalised since 2017. Suitable patients are identified by the paediatric surgical team. Patients, parents and carers are introduced to the idea of a move to adult services often several appointments before a combined paediatric/ adult clinic. This clinic is preceded by a shared formal , standardised summary prepared by the paediatric surgical team. A joint clinic  meeting then takes place in the children’s hospital; a mean of 5 people present at this visit. This introduction in a familiar environment facilitates open discussions and if full transition to adult care is deemed appropriate the next appointment is in the adult clinic. The wide-ranging discussion points are shown in the word-cloud below. A single point of contact in the urology service is provided to the patient to minimise discontinuity before ethe planned review. Due the relatively small numbers in our centre the coordination of this is undertaken by specialist nursing staff. 

When transitions are ad hoc, patients may suffer by undetected renal decline, complications from lost surgical insights, disengagement from care. These system failures are avoidable. These potential harms can be addressed proactively through clinic design, pathway integration, and person-centred coordination. Safe transition is a system output. The SEIPS framework helps us see that structured transitional clinics are not optional but imperative, carefully engineered interventions—designed, implemented, and monitored to protect every patient from the start, in line with the WHO 2025 patient safety vision. 

Andrew Martindale FRCSEd 

Member Urology SSB, RSA East of Scotland