Problem Statement: Healthcare organizations could increase the extent to which they learn from defects.
What is a Defect? A defect is any clinical or operation event or situation that you would not want to happen again. These 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 care givers and administrators identify the types of systems that contributed to the defect and follow-up to ensure safety improvements are achieved.
Who Should Use this Tool: Clinical departmental designee at Morbidity & Mortality Rounds AND Patient care areas as part of the Comprehensive Unit Based Safety Program (CUSP)
All staff involved in the delivery of care related to this defect should be present when this defect is evaluated. At a minimum, this should include the physician, nurse and administrator and other selected professions as appropriate (e.g. medication defect include pharmacy, equipment defect include clinical engineering).
How to Use this Tool:
Complete this tool on at least one defect per month. In addition, departments should investigate all of the following defects: liability claims, sentinel events, events for which risk management is notified, case presented to M&M and healthcare acquired infections. See form for the investigation process.
