Purpose: To identify the types of systems that contributed to the defect (an event or situation that you do not want to happen again) and to plan the followup steps needed to improve safety.
Who should use this tool? Senior leaders, facility team leads, team members.
How should you use this tool? Senior leaders and teams should complete this tool together.
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1. What happened? (brief description)
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2. Why did it happen? (what factors contributed) |
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positive factors What prevented it from being worse?
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negative factors What happened to cause the defect?
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3. What did we do to manage it?
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4. What can we do to reduce the risk of it happening again? |
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Action Plan |
Responsible Person |
Targeted Date |
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5. How will we know risk is reduced?
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With whom will we share our learning? (communication plan) |
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Who |
When |
How |
Followup |
