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Toolkit for MRSA Prevention in ICU & Non-ICU Settings

Learning From Defects

CUSP and MRSA Prevention

A defect is broadly defined as "Anything you do not want to have happen again."

Every system, no matter how well designed, will include failures. CUSP recognizes that patient safety and quality is a part of the system and provides a structure to facilitate systemic change. Identifying defects allows us to address and fix potential issues.

There are four key questions in the CUSP Learning From Defects process:

  1. What happened?
  2. Why did it happen?
  3. How will you reduce the likelihood of this defect from happening again?
  4. How will you know the risk is reduced?

Presentations

After viewing this presentation, viewers will be able to:

  • Describe a process to help teams learn from defects.
  • Explore the Learning From Defects tool.
  • Work through an example of a defect and the process of Learning From Defects with the Investigating A Defect Worksheet.

Documents:

CUSP Tools & Other Resources

CUSP Tool: Staff Safety Assessment (DOCX, 388 KB)

This form is intended to be used as a survey among frontline healthcare workers to determine what risks are present in the unit or facility.

CUSP Tool: Learning From Defects Tool for MRSA Prevention (DOCX, 402 KB)

Guides teams through the process of Learning From Defects.

Below is an example of a completed Learning From Defects form:

CUSP Tool: Investigating A Defect Worksheet (DOCX, 406 KB)

Summary worksheet of the Learning From Defects process.

Identify Defects Through Sensemaking (Â鶹´«Ã½ Core CUSP Toolkit)

To learn more on the Learning From Defects process, follow this link to the Identify Defects Through Sensemaking module of the Â鶹´«Ã½ Core CUSP Toolkit.

 

Page last reviewed October 2024
Page originally created October 2024

Internet Citation: Learning From Defects. Content last reviewed October 2024. Agency for Healthcare Research and Quality, Rockville, MD.
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