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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)