Mistake-Proofing the Design of Health Care Processes

Mistake-Proofing the Design of Health Care Processes is a synthesis of practical examples from the real world of health care on the use of process or design features to prevent medical errors or the negative impact of errors. It contains over 150 examples of mistake-proofing that can be applied in health care—and in many cases relatively inexpensively.

This book is available for free in electronic form directly from the Agency for Healthcare Research and Quality. Single copies are available at no cost by calling AHRQ's Publications Clearinghouse at (800) 358-9295 or by sending a request with the title and publication number to ahrqpubs@ahrq.hhs.gov:

• Print copy: AHRQ Publication No. 07-0020
• CD-ROM version: AHRQ Publication No. 07-0020-CD

An important addition to patient safety literature, this work draws on examples contributed by clinicians in the field as well as research from several academic disciplines. The focus is on what works to reduce medical errors for the in-the-trenches workers who face important decisions, judgments, and risks every day while performing their jobs. This volume draws on the groundbreaking writings of Shingo Shingeo, innovative solutions from nurses at a regional medical center, architects in the center of the current hospital design revolution, and many others.

From the Introduction

The process of turning on a burner on a stove is a simple one. It is an everyday task that most people have performed hundreds of times. Have you ever turned on the wrong burner? Have you ever gone from one room to another in your house only to forget why you went there in the first place? Have you ever put something in the refrigerator that belonged in the cupboard?

These are common errors. Their consequences are usually not very serious. Once you have made these errors, what can you do to ensure that they never happen again? Are willpower and determination enough to avoid them? If one believes that "to err is human," then the answer to these questions is, "No." People who make these errors are not unmotivated or negligent. More importantly, they cannot eliminate the errors simply by telling themselves to do better and deciding not to commit them. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) adds that "it assumes that no matter how knowledgeable or careful people are, errors will occur in some situations and may even be likely to occur."

If executed correctly, many of the tasks that medical professionals perform as part of their jobs offer the potential to heal. The same tasks performed incorrectly, however, can also contribute to harming patients.

Clinicians need to become comfortable performing a wide variety of tasks, some of which are not very different from those performed in everyday life. If the infusion pump does not behave the way a nurse intended it to because the wrong control was adjusted, is the cause of the error really much different from turning on the wrong burner on the stove? The main difference between health care errors and errors in everyday life is that errors that occur in a health care setting can result in serious harm or death.

Whether outcomes are insignificant or life threatening, one question remains to be asked: "What can be done to reduce or eliminate errors and their negative consequences?" Part of the answer, mistake-proofing, is the focus of this book. No single tool can solve every problem; often, the answer will lie in the discovery, implementation, and execution of several tools. Croteau and Schyve state that "techniques for designing safe processes are known, waiting only to be adapted to health care." Mistake-proofing is one of these techniques; it is a crucial addition to the tools employed to improve patient safety.

Mistake-Proofing Defined

Mistake-proofing is the use of process or design features to prevent errors or the negative impact of errors. Mistake-proofing is also known as poka-yoke (pronounced pokayokay), Japanese slang for "avoiding inadvertent errors." Shigeo Shingo formalized mistake-proofing as part of his contribution to the production system for Toyota automobiles. There are substantial differences between automotive manufacturing and health care operations, yet at least a few health care organizations are beginning to incorporate aspects of the Toyota production system into their efforts to reduce medical errors.

John Grout, Ph.D.
John is dean of the Campbell School of Business at Berry College, Rome, Georgia, and the David C. Garrett Jr. Professor of Business Administration. He has researched mistake-proofing extensively for the past 17 years. In 2004 John received the Shingo Prize for his paper, The Human Side of Mistake-Proofing with Douglas Stewart.

John has worked with numerous hospitals, health care systems and medical firms including governmental agencies in the US and UK. John has also been involved in working with firms on mistake-proofing including Automotive, Aerospace, and other manufacturing firms. John has also taught at the Pennsylvania State University and Southern Methodist University. He has taught courses in operations and service management, quality, statistics, process improvement, quantitative methods, and materials management. John has managerial experience in scheduling and production control in the semiconductor industry working for a subsidiary of N.V. Philips. He has a Ph.D. from the Pennsylvania State University in Management Science and a bachelor’s degree from Brigham Young University in Operations and Systems Analysis.

• Improving Healthcare Quality and Patient Safety through Lean Methods
  The lean methodology and management system provides a number of approaches for improving quality and patient safety in very practical ways. One of these lean quality methods is called mistake-proofing, sometimes called "poka-yoke." In health care, this is often called a "forcing function." Mistake-proofing is born of common sense, simplicity and detailed process knowledge, but combines nicely with the findings of cognitive psychology and human factors engineering. It is an ideal tool to improve the recommended actions that come out of teams doing pro-active risk assessment, FMEA or root cause analysis. The vocabulary and approaches included in this seminar will provide these teams with the skills and knowledge to permanently change processes in ways that reduce human errors and lead to more precise actions and outcomes. If you are using double and triple checks in your process and still have errors… If you depend on the vigilance of workers to stop errors…this seminar is for you.
• Mistake Proofing to Reduce Medical Errors Webinar