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Facilitating factors Challenging factors A “burning platform” following two Fear of reprisal very tragic adverse events Strong leadership support Strong program and professional autonomy Good quality improvement culture Inconsistent follow-up of ideas and infrastructure and initiatives Well established morbidity and Fragmented risk-reporting mortality review processes systems Clinical information systems with Fragmented clinical information computerized provider order entry and systems electronic order set capability Committed teams Relatively young workforce Compelling mission to improve Inconsistent application of the health of children policies, procedures and guidelines Designing an Agenda for Change

Building from the Blueprint for Patient Safety at the Hospital for Sick Children