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BACKGROUND: Adverse health care events are injuries occurring as a result of patient care. Significant acute pain is often caused by medical and surgical procedures in children, and it has been argued that undermanaged pain should be considered to be an adverse event. Indicators are often used to identify other potential adverse events. There are currently no validated indicators for undertreated pediatric pain.OBJECTIVES: To develop a preliminary list of indicators of undermanaged pain in hospitalized pediatric patients.METHODS: The Delphi technique was used to survey experts in pediatric pain management and quality improvement. The first round used an electronic questionnaire to ask: “In your opinion, what indicators would signify that acute pain in a child has not been adequately controlled?” Responses were grouped together in semantically similar themes, providing a list of possible adverse event indicators. Using this list, an electronic questionnaire was developed for round 2 asking respondents to indicate the importance of each potential indicator.RESULTS: All but one indicator achieved a level of consensus ≥70%. Separate indicators emerged for postoperative and procedural pain. An additional distinction was made between indicators that could be identified by chart review and those requiring observation of practice and assessment from the child or parent.DISCUSSION: The adverse care indicators developed in the present study require further refinement. There is a need to test their clinical usability and to determine whether these indicators actually identify undermanaged pain in clinical practice. The present study is an important first step in identifying undermanaged pain in hospital and treating it as an adverse event.CONCLUSION: The adverse care indicators developed in the present study are the first step in conceptualizing mismanaged pain as an adverse event.

IWK Health Centre and Dalhousie University, Halifax, Nova Scotia Correspondence: Dr Patrick J McGrath, IWK Health Centre, 5850/5950 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8. Telephone 902-470-6511, fax 902-470-6767, e-mail Patrick.mcgrath@iwk.nshealth.ca Pain research in infants, children and youth has come a long way since the 1970s and 1980s, when it was seriously debated whether children, especially young children, really experienced pain. Now, there is virtually universal agreement that infants and children experience pain. Just over a decade ago, we edited a book on pain measurement in children (1). This special issue of Pain Research & Management is a reprise of this topic. This collection of papers focuses on the latest developments in pain assessment and measurement. The authors are all leading contributors on their topics and they present the latest thinking in their area. Pain is still measured by self-report, behaviour and physiology, but there are new and more sophisticated ways of obtaining behavioural and self-report measures. There has not been enough new work on physiological strategies of measuring pain to warrant a review. We believe that the development of various brain measures of pain will be an exciting area in the future. These papers are derived from the keynote addresses given October 2 to 5, 2008, at the 7th Biennial International Forum on Pediatric Pain, held at White Point Beach Resort, Nova Scotia. The authors have used the best scientific evidence to challenge our thinking about pain measurement in children, and we hope that Pain Research & Management readers find these papers interesting, helpful and provocative. Editorial

Culture is commonly regarded as a factor in pain behaviour and experience, but the meaning of the term is often unclear. There is little evidence that pain perception is modified by cultural or ethnic factors, but pain expression by children and interpretation by caregivers may be affected by the culture of the patient or the caregiver. The present paper examines some of the research regarding cultural influences on children’s pain assessment, and addresses directions for future research. A focus on cultural influences should not distract clinicians from the need to be sensitive to individual beliefs and attitudes.