The Minnesota Department of Human Services has trained 1,500 staff in a child protection fatality review process developed by Collaborative Safety, LLC. It is grounded in safety science, the methodology used to review accidents in the hospital and airline industries.
This protocol analyzes systemic reasons for fatalities rather than focusing on individual caseworker lapses. It reduced deaths from unsafe sleeping practices in Tennessee by 50%, and helped lower staff turnover in Arizona from 60% to 25%.
The approach echoes Continuous Quality Improvement research, which shows that 85% of defects on assembly lines and mistakes in business processes are caused by systemic problems, not worker errors.
Counties continue to disregard their legal obligation to make fatality reviews public. This state initiative could inspire more openness and, most importantly, reduce child fatalities.