First used in 1729, the term "Coming of Age" has many meanings and defines many traditions. In cultural and religious settings, it implies transition from childhood to adulthood, with attendant rights and responsibilities that come with the newly acquired status. Other Coming of Age definitions include attaining prominence, respectability, recognition, or maturity. An example of a Coming of Age tradition in medicine is the White Coat Ceremony, celebrated in many medical schools. It marks the transition from preclinical, basic science years to clinical years when students have some of their first encounters with patients and begin their actual practice of medicine, albeit carefully supervised by attending physicians.

We submit that pediatric quality and safety, an important branch of improvement science, has Come of Age. It has attained a level of respected prominence and recognized maturity. To make that point, a look back at the articles published 10 years ago in the Journal for Healthcare Quality compared with the current issue is informative. For 2007, articles and interviews published during that year reflected the then-current thinking: focusing on defining quality, quality improvement (QI) methods, related metrics, and tools found useful in change management. Only two of the 43 articles and interviews were related to pediatrics-both were observational studies and neither documented any interventions or improvement. Contrast that to the current issue where five of the six articles relate to pediatric quality and safety. These studies evaluate systems and processes in multiple pediatric settings, each providing information that is useful and contributes to better understanding about how to improve outcomes in a clearly defined metric. The sophistication demonstrated in these articles reflects the progress made in the field in just 10 years.

Other signs of maturity in pediatric quality and safety include the demonstrated ability of children's hospitals to band together and eschew competition when it comes to patient safety. Specifically, the Solutions for Patient Safety (SPS) is a national collaborative including more than 130 children's hospitals that have combined forces to work toward eliminating many hospital-acquired conditions and have demonstrated remarkable success.1,2 Unlike children, who often have difficulty sharing, the hallmark of SPS is the hospitals' commitment to share their results: successes and failures. "All teach, all learn" is the mantra for SPS, and a great deal of patient harm has been avoided as a result.1,2 Finally, recognition is evidenced by the establishment of a journal, Pediatric Quality and Safety, dedicated solely to the field.3

Coming of Age brings with it adult responsibilities. For pediatric quality and safety, maintaining the highest QI scientific standards means working to integrate QI science into the curriculum of our trainees and recognizing it in administrative and academic promotion algorithms of our teaching institutions.4 Further, it means using improvement science to help children achieve their full potential and in the arena of inpatient pediatric care, continuing to push toward the aspirational, albeit elusive goal of eliminating preventable harm to our patients. Although dramatic and sustained reductions in preventable harm have been demonstrated,5,6 elimination remains the goal. Improvement techniques, prevalent to date, have mostly involved retrospectively investigating what went wrong and redesigning system processes and individual behaviors to prevent similar future occurrences (often referred to as "Safety I"). A new approach, "Safety II", emphasizes flexibility and resilience within the system necessary to avoid unforeseen or unexpected risks.7 To date, this is a theoretical concept that has not been validated in the health care setting, but we believe if implemented, it can take pediatric quality and safety to new heights.

This is an exciting time to be working in pediatric quality and safety. The field has Come of Age, the pace of progress is accelerating rapidly and our patients are benefitting. The articles presented in this issue of the Journal for Healthcare Quality are a testament to that assertion.

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