Learn From Defects - Implementation Guide

Purpose: To identify the types of systems that contributed to the defect (an event or situation that you do not want to happen again) and to plan the followup steps needed to improve safety.

Who should use this tool? Senior leaders, facility team leads, team members.

How should you use this tool? Senior leaders and teams should complete this tool together.

1. What happened? (brief description)


2. Why did it happen? (what factors contributed)

positive factors

What prevented it from being worse?


negative factors

What happened to cause the defect?


3. What did we do to manage it?


4. What can we do to reduce the risk of it happening again?

Action Plan

Responsible Person

Targeted Date


5. How will we know risk is reduced?
Were the above action plans effectively carried out? Did the interventions reduce the likelihood of recurrence of the defect? Has it happened again?


With whom will we share our learning? (communication plan)





Page last reviewed May 2017
Page originally created April 2017
Internet Citation: Learn From Defects - Implementation Guide. Content last reviewed May 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/defects.html
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