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Delirium is associated with poor outcomes in adults but is less extensively studied in children.To describe a quality improvement initiative to implement delirium assessment in a pediatric intensive care unit and to identify barriers to delirium screening completion.A survey identified perceived barriers to delirium assessment. Failure modes and effects analysis characterized factors likely to impede assessment. A randomized case-control study evaluated factors affecting assessment by comparing patients always assessed with patients never assessed.Delirium assessment was completed in 57% of opportunities over 1 year, with 2% positive screen results. Education improved screening completion by 20%. Barriers to assessment identified by survey (n = 25) included remembering to complete assessments, documentation outside workflow, and “busy patient.” Factors with high risk prediction numbers were lack of time and paper charting. Patients always assessed had more severe illness (median Pediatric Index of Mortality 2 score, 0.90 vs 0.36; P < .001), more developmental disabilities (moderate to severe pediatric cerebral performance category score, 54% vs 32%; P = .007), and admission during lower pediatric intensive care unit census (median [interquartile range], 10 [9-12] vs 12 [10-13]; P < .001) than did those never assessed (each group, n = 80). Patients receiving mechanical ventilation were less likely to be assessed (41.0% vs 51.2%, P < .001).Successful implementation of pediatric delirium screening may be associated with early use of quality improvement tools to identify assessment barriers, comprehensive education, monitoring system with feedback, multidisciplinary team involvement, and incorporation into nursing workflow models.