Suicide is a leading cause of death for pediatric patients in the United States. The utilization of protective observation strategies, namely constant observation, is a regulatory recommendation as part of a comprehensive suicide prevention plan for hospitalized behavioral health patients. Constant observation is the increased level of observation and supervision with continuous one-to-one monitoring techniques, taken to assure the safety and well-being of a patient and others in the patient care environment (Moore et al., 1995). This evidence-based practice inquiry describes a search for the best evidence on constant observation practices ensuring the safe care of pediatric patients at risk for self-harm or suicide. The findings included no high-level evidence, however four literary themes related to the challenges of constant observation emerged: confusing language and definitions, untested models of care, important privacy issues and lack of pediatric observation strategies for patients at risk for self-harm and suicide. Impaired communication underscored each of the themes.