Section: Applying CUSP to MRSA and SSI Prevention
Step 4 of the Comprehensive Unit-based Safety Program (CUSP) is “Learning From Defects.” According to CUSP, a defect is broadly defined as “Anything you do not want to happen again.”
Every system, no matter how well designed, will include failures. CUSP recognizes that, in most cases, patient safety and quality are parts of the system, rather than results of the actions of individual caregivers, and provide a structure to facilitate systemic change.
Identifying these failures allows us to address and fix a defect. There are four key questions in the CUSP Learning From Defects process:
- What happened?
- Why did it happen?
- What will we do to reduce the risk of this happening again?
- How will we know that we succeeded?
Presentations
Presentation: Learning From Defects
After reviewing the content of 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:
- Learning From Defects – Slides (PPTX, 5 MB)
- Learning From Defects - Facilitator Guide (DOCX, 5 MB)
Presentation: Learning From Defects: Applying the Swiss Cheese Model of System Failures
After reviewing the content of this presentation, viewers will be able to—
- Review the definition of a defect
- Review the “Swiss cheese model” of system failure
- Apply a patient example to discover system failures
Documents:
Tools and Resources
CUSP Tool: Learning From Defects Tool (DOCX, 406 KB)
Guides teams through the process of Learning From Defects.
Tool: Learning From Defects Completed Form (DOCX, 411 KB)
An example of a completed Learning From Defects form.
CUSP Tool: Staff Safety Assessment (DOCX, 381 KB)
Gathers staff insight on safety issues and areas for improvement.
Understand the Science of Safety (Core CUSP Toolkit)
The “Science of Safety” is the fundamental theory that underpins the CUSP model. Follow this link to the Science of Safety topic of the Core CUSP Toolkit. It is often recommended that CUSP team members make sure to review this section at the start.
