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)