We report a retrospective analysis of 84 consecutive pediatrics-related internal review files opened by a medical center’s risk managers between 1996 and 2001. The aims were to identify common causative factors associated with adverse events/adverse outcomes (AEs) in a Pediatrics Department, then suggest ways to improve care. The main outcome was identification of any patterns of factors that contributed to AEs so that interventions could be designed to address them. Cases were noted to have at least one apparent contributing problem; the most common were with communication (44% of cases), diagnosis and treatment (37%), medication errors (20%), and IV/Central line issues (17%). 45% of files involved a child with an underlying diagnosis putting her/him at high risk for an adverse outcome. All Pediatrics Departments face multiple challenges in assuring consistent quality care. The extent to which the data generalize to other institutions is unknown. However, the data suggest that systematic analysis of aggregated claims files may help identify and drive opportunities for improvement in care.