Learn from Defects Tool

CUSP Toolkit

Health care organizations can increase the extent to which they learn from defects.

Problem statement: Health care organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that a future patient will be harmed. Most often clinicians recover from mistakes by reducing risks to the patient who suffered a defect.

What is a defect? A defect is any clinical or operational event or situation that you would not want to have happen again. This could include incidents that you believe caused patient harm or put patients at risk for significant harm.

Purpose of tool: The purpose of this tool is to provide a structured approach to help staff and administrators identify the types of systems that contributed to the defect and to followup to ensure safety improvements are achieved.

Who should use this tool? Health care providers.

All staff involved in the delivery of care related to a defect should be present when this defect is evaluated. At a minimum, this should include the physician, nurse, administrator, and other selected professionals as appropriate (e.g., for a medication defect, include pharmacy staff; for an equipment defect, include clinical engineering staff).

How to use this tool: Complete the form below for at least one defect per month. Investigate all of the following defects: Liability claims, sentinel events, events for which risk management is notified, cases presented at morbidity and mortality rounds, and healthcare-acquired infections.

  1. Provide a clear, thorough, and objective explanation of what happened.
  2. Review the list of factors that contributed to the incident and check off those that negatively and positively contributed to the outcome of the incident. Negative contributing factors are those that harmed or increased the risk of harm for a patient. Positive contributing factors limited the amount of harm. Rate the most important contributing factors that relate to the incident.
  3. Describe how you will reduce the likelihood of this defect from happening again by completing the tables. Develop interventions for each important contributing factor, and rate each intervention for its ability to mitigate the defect and to carried out. Identify two to five interventions that you will use. List whatyou will do, who will lead the intervention, and when you will followup to note the intervention's progress.
  4. Describe how you know you have reduced the risk. Survey frontline staff involved in the incident to determine whether the intervention has been used effectively and whether risk has been reduced.

Investigation process

  1. What happened? Reconstruct the timeline and explain what happened. For this investigation, put yourself in the place of those involved and in the middle of the event as it was unfolding to understand what they were thinking and the reasoning behind their actions or decisions. Try to view the world as they did when the event occurred.
  2. Why did it happen? Below is a framework to help you review and evaluate your case. Please read each contributing factor and evaluate whether it was involved. If it was involved, did it negatively contribute (increase harm) or positively contribute (reduce impact of harm) to the incident? Rate the most important negatively contributed and positively contributed factors that relate to this event.
Contributing FactorsNegatively ContributedPositively ContributedN/A
Patient   
Patient was acutely ill or agitated. (Elderly patient in renal failure, secondary to congestive heart failure.)   
There was a language barrier. (Patient did not speak English.)   
There were personal or social issues. (Patient declined therapy.)   
Task   
Was there a protocol available to guide therapy? (Protocol for mixing medication concentrations is posted above the medication bin.)   
Were test results available to help make the care decision? (Stat blood glucose results were sent in 20 minutes.)   
Were tests results accurate? (Four diagnostic tests done. Only MRI results needed quickly and results were faxed.)   
Provider   
Was the provider fatigued? (Provider was tired at the end of a double shift, or provider forgot to take a blood pressure reading.)   
Did the provider's outlook or perception of his or her own professional role affect this event? (Doctor followed up to make sure cardiac consult was done expeditiously.)   
Was the provider's physical or mental health a factor? (Provider distracted with personal issues and missed hearing an order.)   
Team   
Was verbal or written communication during hand-offs clear, accurate, clinically relevant, and goal directed? (Oncoming care team was debriefed by outgoing staff regarding patient's condition.)   
Was verbal or written communication during care clear, accurate, clinically relevant, and goal directed? (Staff member was comfortable expressing his or her concern regarding high medication dose.)   
Was verbal or written communication during a crisis clear, accurate, clinically relevant, and goal directed? (Team leader quickly explained and directed his or her team regarding the plan of action.)   
Was there a cohesive team structure with an identified and communicative leader? (Attending physician gave clear instructions to the team.)   
Training and Education   
Was provider knowledgeable, skilled, and competent? (Nurse knew dose ordered was not standard for that medication.)   
Did provider follow the established protocol? (Provider pulled protocol to ensure steps were followed.)   
Did the provider seek supervision or help? (New nurse asked preceptor to help him or her mix the medication concentration.)   
Information Technology or Computerized Physician Order Entry   
Did the computer or software program generate an error? (Heparin was chosen, but Digoxin was printed on the order sheet.)   
Did the computer or software program malfunction? (Computer shut down in the middle of provider's order entry.)   
Did the user check what he or she entered to make sure it was correct? (Provider initially chose .25 mg, but caught his or her error and changed it to .025 mg.)   
Local Environment   
Was there adequate equipment available and was the equipment working properly? (There were two extra ventilators stocked and recently serviced by clinical engineering.)   
Was there adequate operational (administrative and managerial) support? (Unit clerk was out sick but an extra clerk was sent to cover from another unit.)   
Was the physical environment conducive to enhancing patient care? (All beds were visible from the nurse's station.)   
Were there enough staff on the unit to care for patient volume? (Nurse ratio was 1:1.)   
Was there a good mix of skilled with new staff? (There was a nurse orientee shadowing a senior nurse and an extra nurse to cover the senior nurse's responsibilities.)   
Did workload affect the provision of good care? (Nurse caring for three patients because another nurse went home sick.)   
Institutional Environment   
Were adequate financial resources available? (Unit requested experienced patient transport team for critical patients, and one was made available the next day.)   
Were laboratory technicians adequately in-serviced or educated? (Lab tech was fully aware of complications related to thallium injection.)   
Was there adequate staffing in the laboratory to run results? (There were three dedicated laboratory technicians to run stat results.)   
Were pharmacists adequately in-service or educated? (Pharmacists knew and followed the protocol for stat medication orders.)   
Did pharmacy have a good infrastructure (e.g., policies and procedures)? (It was standard policy to have a second pharmacist do an independent check before dispensing medications.)   
Was there adequate pharmacy staffing? (There was a pharmacist dedicated to the ICU.)   
Does hospital administration work with the units regarding what and how to support their needs? (Guidelines hold new ICU admissions in the emergency department when beds are not available in the ICU.)   

Review the list of contributing factors above and identify the most important ones related to this event. Rate each contributing factor on its importance to this and future events. 

Contributing FactorsImportance to
Current Event, 1
(Low) to 5 (High)
Importance to
Future Events, 1
(Low) to 5 (High
   
   
   
   
   

How will you reduce the likelihood of this defect happening again? Develop an intervention for each important contributing factor identified. Develop interventions to defend against the two to five most important contributing factors. Refer to the Strength of Interventions chart below for examples of strong and weak interventions and then rate each intervention on its ability to mitigate the contributing factor and on the team's belief that the intervention will be carried out. Make an action plan for two to five of the highest scoring interventions. 

Interventions To Reduce the Risk of the DefectAbility To Mitigate
the Contributing Factor,
1 (Low to 5 (High)
Team's Belief That
the Intervention Will
Be Implemented
and Executed,
1 (Low) to 5 (High)
   
   
   
   
   

Select two to five of the highest scoring interventions and develop an action plan to put them in place. 

Specific Interventions To Reduce the Risk of the DefectWho Will Lead This Effort?Followup Date
   
   
   

 

*Strength of Interventions

Weaker ActionsIntermediate ActionsStronger Actions
Double checkChecklists or cognitive aidArchitectural or physical plant changes
Warnings and labelsIncreased staffing or reduced workloadTangible involvement and action by leadership in support of patient safety
New procedure, memorandum, or policyRedundancySimplify the process or remove unnecessary steps
Training and educationEnhance communication (e.g., check-back, SBAR)Standardize equipment and process of care map
Additional study or analysisSoftware enhancement or modificationsNew device usability testing before purchasing
 Eliminate look-alike and sound- alike drugsEngineering control of interlock (forcing functions)
 Eliminate or reduce distractions 

IV. How will you know the risk is reduced? Ask frontline staff involved in the defect whether the interventions reduced the likelihood of recurrence of the defect. After the interventions have been put in place, complete the “Describe Defect” and “Interventions” sections and have staff rate the interventions. 

Describe Defect:  
InterventionsIntervention Was
Effectively Carried Out,
1 (Low) to 5 (High)
Intervention Reduced
the Likelihood of
Recurrence, 1
(Low) to 5 (High)
   
   
   
Page last reviewed December 2012
Internet Citation: Learn from Defects Tool: CUSP Toolkit. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.html