{"id":32493,"date":"2026-01-30T09:43:08","date_gmt":"2026-01-30T17:43:08","guid":{"rendered":"https:\/\/www.casey.org\/?p=32493"},"modified":"2026-07-30T14:46:41","modified_gmt":"2026-07-30T14:46:41","slug":"ciencia-de-la-seguridad-incidente-critico","status":"publish","type":"post","link":"https:\/\/www.casey.org\/es\/safety-science-critical-incident\/","title":{"rendered":"\u00bfC\u00f3mo se aplica la ciencia de la seguridad a las revisiones de incidentes cr\u00edticos?"},"content":{"rendered":"
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Summary<\/h3>\n

This brief explains critical incident reviews, the Safe Systems Improvement Tool, and safety science lessons learned from members of the National Partnership for Child Safety collaborative.<\/em><\/p>\n<\/div>\n \n \n \n <\/div>\n<\/div>\n\n\n

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The death of a child is devastating to families and communities.1<\/sup><\/a>\u00a0When the fatality is related to abuse or neglect, the public, media, and policymakers understandably put pressure on child protection agencies to react quickly, assign responsibility, and craft a plan for corrective action. This can result in the firing of staff, the imposition of new policies and practices, a sudden redirecting of resources, and even the resignation of the child welfare leader.<\/p>\n

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Rarely, however, do punitive-based reactions within a child welfare system result in keeping children more safe. While intended to signal accountability, these responses instead may render child welfare systems less<\/em> able to retain or impose evidence-based system improvements. Such responses therefore often do little to reduce the estimated more than 2,000 child fatalities<\/a> that occur annually in the U.S. due to child abuse or neglect.<\/p>\n

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As a result, the very systems tasked with protecting children often undermine their own effectiveness in the wake of tragedy.<\/strong> Hasty responses limit what a child welfare system will learn from the tragedy. In an effort to ensure that safety practices are deliberate and rooted in data and research, momentum has built for\u00a0applying safety science principles<\/a>\u00a0to child welfare, particularly in the context of critical incident reviews (CIRs).<\/p>\n<\/div>\n \n \n \n <\/div>\n<\/div>\n\n\n

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What are critical incident reviews?<\/h3>\n

Critical incident reviews (CIRs) look at any incident that has the potential to create an unsafe situation and, when studied, can promote learning to prevent further incidents by providing valuable insight regarding systemic flaws. Ideally, a CIR is a supportive, transparent, and multi-disciplinary process to review the circumstances surrounding a tragic incident, such as a child maltreatment fatality or near fatality, with the goal of\u00a0addressing systemic barriers, strengthening case practice, and identifying lessons learned to improve child safety<\/strong>.<\/p>\n<\/div>\n \n \n \n <\/div>\n<\/div>\n\n\n

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A better way to address critical incidents<\/h2>\n \n \n \n

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Grounded in both systems thinking and psychological safety, a\u00a0safety science<\/strong><\/a> framework2<\/sup><\/a>\u00a0can enhance accountability of child protection agencies, using similar methods employed by other complex organizational environments requiring high levels of safety, such as aviation and health care systems.<\/p>\n

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In partnership with various stakeholders including child welfare leaders, policymakers, academics, and practitioners,\u00a0Casey Family Programs launched in 2018 a\u00a0national effort to improve child safety and prevent maltreatment fatalities<\/a>.\u00a0Child welfare agencies from 20 jurisdictions participated in the Tennessee Safety Culture Summit about the application of safety science in child welfare. These efforts culminated in 11 jurisdictions and Casey Family Programs forming the National Partnership for Child Safety<\/a> (NPCS), a quality-improvement collaborative focused on applying safety science in child welfare, specifically to prevent future fatalities and improve child safety through innovations in child protection. The NPCS continues to grow (38 jurisdictions in 2025), with members participating in quality improvement activities related to safety science, including applying a standardized platform for CIRs and sharing data.<\/p>\n<\/div>\n \n \n \n <\/div>\n<\/div>\n\n\n

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Safe Systems Improvement Tool<\/h3>\n

The most widely used tool for child welfare CIRs, the Safe Systems Improvement Tool (SSIT) offers a structured framework to identify systemic factors across four key domains: 1) family circumstances; 2) caseworker role; 3) collaboration across system partners (child welfare, law enforcement, court systems); and 4) systemic environmental factors. The tool addresses services gap, policy limitations, and professional decision-making challenges within each domain. By standardizing data collection and analysis, the SSIT helps child protection agencies strengthen system safety, reduce preventable harm, and drive evidence-based policy reforms.<\/p>\n

The Tennessee Department of Children\u2019s Services initially developed the tool in 2015, and\u00a0NPCS subsequently created its own version of the Safe Systems Improvement Tool<\/a>\u00a0that incorporates the input from additional jurisdictions.<\/p>\n

Some jurisdictions may focus only on child fatalities due to limited capacity, while others might choose to review other critical incidents harmful to children to test the flexibility of the process. Expanding the scope of review not only reveals more areas for study, but also provides more meaningful data to identify opportunities for improved child safety.<\/p>\n<\/div>\n \n \n \n <\/div>\n<\/div>\n\n\n

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The safety science field is valuable when applied to critical incident and child fatality reviews because it is evidence-based, systems-focused, and promotes learning and change through an approach that:<\/p>\n