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Background Mortality among hospitalised children in low-resource settings remains much higher than in high-resource environments. Paediatric Early Warning Systems (PEWSs) have been shown to improve vital signs collection, strengthen interprofessional communication, lower healthcare costs and reduce paediatric hospital mortality in multiple low- and middle-income countries. Providers at Botswana’s national referral center, Princess Marina Hospital (PMH), face significant challenges in identifying children at risk for clinical deterioration.Methods We used PEWS previously validated in resource-limited settings to create the PMH PEWS. We piloted the PMH PEWS from December 2022 to March 2023. We assessed (1) effectiveness of PEWS at reducing unplanned escalations of care by comparing pre-implementation and post implementation rates of clinical deterioration events (unplanned intensive care unit (ICU) transfer; use of inotropic medications, mechanical ventilation or mannitol; cardiopulmonary resuscitation; non-palliative mortality), (2) acceptability and feasibility of PEWS adoption using the acceptability and feasibility of implementation measures and (3) barriers and facilitators to implementation through stakeholder interviews structured around Consolidated Framework for Implementation Research domains.Results The relative frequency of clinical deterioration events changed post-PEWS implementation (p=0.01) such that initiation of mechanical ventilation (12.3% vs 23.2%) and inotropes (18.5% vs 35.7%) decreased while ICU transfers increased (27.7% vs 8.9%). Both doctors and nurses found PEWS to be acceptable and feasible. Staff universally reported that PEWS improved patient care, increased clinician provider accountability for deteriorating patients and strengthened interprofessional communication. Nurses reported greater engagement with PEWS adaptation than doctors. Physical resource limitations and inter- and intra-professional hierarchies were widely endorsed barriers to implementation.Conclusions PEWS has the potential to improve the care of hospitalised children in Botswana by strengthening interprofessional communication and increasing clinician accountability for deteriorating patients.