Objectives To develop an evidence-based paediatric early warning system (PEWS) for use in a specialist children’s hospital.

Methods The five stages of the change management research framework were utilised: Local: ward charts were collected for content analysis. Focus groups explored routine observation and monitoring practices. Grounded theory and triangulation were used for qualitative analysis of the focus group discussions. National: structured telephonic survey to identify existing practices that could be adapted or learned from. International: literature review to identify standards and rationale behind routine physiological observations. A multiprofessional working party correlated the data into an observation and monitoring policy and contributed to the standardised observation chart design.

Results Identified unsubstantiated practices with multiple charts being used, which were synthesised into three standardised charts. Two observation and monitoring policies were identified, which were not able to be adapted. Literature review—four publications identified including National Institute of Health and Clinical Excellence guidance. Iterative process through the working party achieved 90–100% consensus on standards and guidance. The PEWS consists of: an observation and monitoring policy; the first validated PEWS score embedded into standardised observation and fluid balance charts; response algorithm; audit, evaluation and an education programme for bedside carers.

Conclusions Standardising the way bedside carers observe, monitor and document important clinical parameters requires a fundamental cultural change. This service development project utilised a multimodal approach to the development, pilot and refinement of a PEWS that engaged clinical staff at all levels to improve the quality and safety of hospitalised children at Birmingham Children’s Hospital.