102 February 2006 Volume 32 Number 2 Introduction In September 2004, a team of quality and safety researchers at the Johns Hopkins Medical Institutions, Baltimore, developed a practical tool to investigate defects in patient care. The impetus for creating this tool came after the Institute of Medicine targeted incident reporting systems as a method to collect defect information and improve safety. 1–3 To translate data into safety improve- ments, incidents must be investigated and hazards mitigat- ed. The Learning From Defects (LFD) tool provides a structured approach to help caregivers and administrators identify systems that contribute to defects and includes a follow-up mechanism to ensure safety improvements are achieved. It supports the staff’s ability to investigate more incidents closer to the time of the incident and to identify and mitigate a larger number of contributory factors. Tool Description The LFD tool has a one-page user’s guide. The tool is divided into three sections. Section I asks the investiga- tor to explain “what happened.” In section II, investiga- tors are directed to review and check all factors that caused or increased risk of patient harm (negatively con- tributed) and all factors that reduced or eliminated harm (positively contributed). Section III asks the investigator to list specific actions to reduce the likelihood of this defect from happening again, to assign a project leader and follow-up date, and to consider how to evaluate if risk is reduced. Measuring risk reduction could be quali- tative (for example, talk to the users and see if effort mit- igates or prevents defect), or quantitative, such as point prevalence (that is, periodic audit). Tool Application to Quality and/or Safety LFD is a “lighter” version of a root cause analysis (RCA); the contributing factors in the framework are informed by safety expert Charles Vincent’s model of systems. 4,5 LFD enables unit/department-based real-time incident analysis and action planning to enhance safety. An unusual and value-added aspect of the tool is its ability to focus users on positive factors that prevented or miti- gated harm as well as those factors that contributed to the process or system failure. These positive findings can then be considered to enhance safety across a vari- ety of systems and processes. We currently use this framework in the Intensive Care Unit Safety Reporting System 6,7 and recently reported aggregate data on common event types, contributing fac- tors and harm. 6,8 How best to use aggregate data to improve safety is yet unknown. LFD allows for quick yet thorough investigation of defects reported and provides a mechanism to manage improvement activities and measure results. A Practical Tool to Learn From Defects in Patient Care Tool Tutorial Peter J. Pronovost, M.D., Ph.D. Christine G. Holzmueller Elizabeth Martinez, M.D., M.H.S. Christina L. Cafeo, R.N., M.S.N. David Hunt, R.N. Conan Dickson, Ph.D. Michael Awad, M.D., Ph.D. Martin A. Makary, M.D, M.P.H. Readers may submit Tool Tutorial inquiries and submissions to Steven Berman at sberman@jcaho.org. Tina Maund, R.N., M.S., serves as Tool Tutorial editor. Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations