Supervision Saves Lives: Preventing Accidents Through Active Observation Fatality File

Child Injured During Unsupervised Transition

During an indoor-to-outdoor transition, staff assumed all children were lined up and accounted for. One child ran ahead unsupervised, slipped on a wet surface, and struck their head.

The investigation found that supervision coverage was unclear during the transition and that no formal headcount occurred. Procedures were updated to require designated supervision zones and mandatory counts during transitions.

The incident reinforced that assumptions replace supervision, and assumptions fail.

Source: https://pubmed.ncbi.nlm.nih.gov