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).