Patient Safety in Children’s and Neonatal Surgery: A Global Perspective 

In 2025, World Patient Safety Day shines a spotlight on the care of neonates and children. While this focus is timely and essential, it also reveals a stark reality: in many parts of the world, particularly in low- and middle-income countries (LMICs), the concept of patient safety must be redefined. In these regions, the greatest threat to safety is not just substandard care, it’s the absence of care altogether. 

Redefining Patient Safety in LMICs 

Traditionally, patient safety is defined as the absence of preventable harm and the minimisation of risks associated with healthcare. However, in LMICs, especially in sub-Saharan Africa, the conversation must shift. Here, the lack of access to surgical care for children and newborns is itself a form of harm. The challenge is not only about improving standards but also about ensuring that care is available in the first place. 

Understanding the scale of the problem is daunting. The population under 18 in sub-Saharan Africa is approximately 500 million and is projected to reach 1 billion by 2050, half the continent’s population. In contrast, this age group makes up only 35% of the population in the rest of the world. 

The Scope of the Crisis 

The statistics are staggering: 

These numbers underscore a crisis of access, not just quality. The consequences are reflected in mortality rates: 

These figures highlight the urgent need for a new mindset when addressing patient safety in these regions. 

Neonatal Care: A Unique Challenge 

Caring for newborns, especially premature infants, demands advanced technology and highly skilled staff - resources that are scarce in most sub-Saharan African facilities. The earlier the gestation, the greater the dependency on intensive care and specialised equipment. Yet, geographic, financial, and infrastructural barriers severely limit access, particularly in rural areas. 

Many babies are born far from maternity facilities, often arriving late or not at all due to the prohibitive cost of transportation. The lack of skilled midwives and delivery partners exacerbates the risks. Complicated labours, postpartum haemorrhage, and the absence of essential interventions like blood transfusions are common challenges. 

In high-income countries, neonatal safety involves infection control, ventilation, and nutritional support. In LMICs, the absence of these basic services is the primary threat. Here, safety is compromised not by deviation from best practices, but by the inability to deliver care at all. 

Infrastructure and Workforce Deficiencies 

Beyond access, other threats to safety include: 

These challenges demand innovative solutions tailored to the realities of LMICs. 

A Model for Change: Kids Operating Room 

One organisation leading the charge is Kids Operating Room, a Scottish charity committed to transforming surgical care for children in resource-limited settings. Their approach aligns with the Lancet Commission’s framework: Stuff, Staff, Space, Systems. 

Stuff: Equipping Operating Rooms 

Since 2018, Kids Operating Room has installed 103 paediatric operating theatres across LMICs, primarily in sub-Saharan Africa. Each theatre is designed specifically for children and neonates, equipped with over 3,300 items, including: 

A standout innovation is the installation of solar panels on each theatre’s roof. These panels feed into smart batteries, providing up to eight hours of electricity - crucial during power outages that would otherwise compromise care. 

Fig 2 KIDS OR Scholars and staff in Blantyre, Malawi with Prof Eric Borgstein FRCSEd, Chief of Surgery. 

Space: Creating Healing Environments 

Each Kids Operating Room project includes child-friendly waiting and recovery areas, designed to comfort both children and their caregivers. These spaces promote holistic healing and reduce the trauma often associated with hospital visits. 

Systems: Strengthening the Foundations 

Kids Operating Room addresses systemic challenges by: 

To date, Kids Operating Room has enabled 711,000 children to receive surgical procedures that would otherwise not have taken place. 

Sustainable, Safe, and Local 

Unlike short-term missions by foreign surgical teams, Kids Operating Room’s model emphasises local empowerment. By investing in local clinicians and infrastructure, they ensure continuity of care and long-term safety. This approach avoids the risks associated with temporary interventions, such as inadequate follow-up care. 

However, the presence of equipment and trained staff does not automatically guarantee safety. Kids Operating Room recognises the importance of ongoing learning, audit, and quality assurance. Their surveys reveal significant gaps in data collection and safety practices, such as: 

While some may view these tools as luxuries in overstretched systems, others argue they are essential. Every child deserves safe care, regardless of geography or socioeconomic status. 

Looking Ahead: A Call to Action 

Having identified the need, it is time for broader collaboration. Kids Operating Room could partner with institutions like the Royal College of Surgeons of Edinburgh (RCSEd) and regional bodies such as: 

Together, they could develop and implement safety standards tailored to the unique challenges of these regions. The newly established Global Care facility at RCSEd might serve as a hub for such initiatives. 

Conclusion 

Patient safety in children’s and neonatal surgery is a global issue - but in LMICs, it demands a radically different approach. The absence of care is the greatest threat, and addressing it requires innovation, investment, and collaboration. Organisations like Kids Operating Room are proving that change is possible. By equipping local teams, building infrastructure, and advocating for systemic reform, they are not only saving lives - but they are also redefining what safe care means for the world’s most vulnerable patients. 

George G Youngson CBE, FRCSEd 

Trustee, Kids Operating Room. www.kidsor.org