serious safety events
learning from our mistakes
why is this a priority for us?
- Investigating our mistakes allows us to find the causes and fix our system so we won’t repeat our errors
- We want to do everything we can to eliminate harm to our patients
what are we doing to reduce mistakes?
- Everyone at Dayton Children’s is trained in error prevention techniques to help reduce errors
- We investigate errors to understand the problems in our system which allowed the error to occur
- We institute action plans based on the findings to fix our system
what do we measure?
- We measure the number of serious safety events that occur in our organization
- A serious safety event is when we have a deviation in our standard practice that causes moderate to severe harm
- Individual events are represented by a bar on the graph
- We divide this by 10,000 patient days to get our rate (the line on the graph)