Objectives: Following two fatal accidents during pediatric procedural sedation (PS), we investigated the level of adherence to established safety standards on PS in a nationwide cohort of fully trained general pediatricians, entrusted with PS. Study design and methods: Sample survey. Safety guidelines on PS were split into 4 domains (‘Presedation Assessment’, ‘Monitoring during PS’, ‘Recovery after PS’ and ‘Facilities and Competences for Emergencies and Rescue’). Each domain was operationalized into subdomains and items. Items were presented within a questionnaire list as procedural points of attention on which respondents could give their personal adherence score. Percentages of full adherence were calculated. Non-adherence was defined as gradual deviation from full adherence. After factor and reliability analysis, observed scores were summed up to scales and results were transformed to a 0-10 report mark (RM). A RM of ≥ 9 is considered as a satisfactory level of adherence while an RM < 6 is considered as unacceptably low. Results: Full adherence was rare. For most (sub)domains only a minority of respondents achieved a satisfactory level of adherence. Large numbers of respondents had scores below 6. Conclusions: Potentially unsafe PS practices are common under Dutch general pediatricians, despite the availability of guidelines. The design of guidelines should include a goal-directed plan for implementation including training, initiatives for continuous quality assurance and improvement and repeated measurements of adherence to guidelines.