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Mistake Proofing Webinar Follow-up Q & A


Mistake Proofing Webinar Follow-up Q & A

John Grout responds to your questions that we couldn’t get to during the webinar Mistake Proofing to Reduce Medical Errors.

Q. In traffic planning, roundabouts have reduced the number of accidents/fatalities, the assumption being that people need to think instead of depending on others to follow traffic signals! Thoughts?

A. One of the few accidents I've had was in a traffic circle (roundabout), so I may be the wrong person to ask. My own perception is that navigating a traffic circle is a more demanding cognitive task than is going through an intersection controlled by a traffic signal. The idea that processes should be structured in such a way that more deliberative thought is needed and that would defy standardization and the use of autopilot is an interesting one. Until I have studied it more thoroughly, my intuition will continue to be that adding more complexity would not be the direction I would recommend when searching for process improvement methods.

Q. Some of the early mistake-proofing examples you showed looked more like visual indicators, not mistake proofing — they make the right action more likely — not certain. Is this really prevention?

A. My view of mistake-proofing is relatively broad and includes visual indicators as well as more "ironclad" prevention techniques.

Q. Why do hospitals not follow a best practice from the FDA— process validation using IQ/OP/PQ?

A. This is an interesting question. Instead of asking about hospitals we might equally well ask it about teams, groups, and individuals. Why does anyone not follow best practice? I think the answer probably lies in the old discipline of applied behavior analysis (ABA). ABA suggests that the strongest motivators are those which are soon, certain, and positive. The reason best practices are not followed is usually because they are not perceived to lead immediately to the best possible outcome with complete certainty. For a more thorough treatment of this question, I recommend reading the following article. Repenning, N. and J. Sterman (2001). Nobody Ever Gets Credit for Fixing Defects that Didn't Happen: Creating and Sustaining process Improvement, California Management Review, 43, 4: 64-88.

Q. When completing a FMEA, is there a standard "weighting" standard for the numerators such as the ones available for FMEA in automotive/manufacturing?

A. There is no standard scale for the factors that make up the risk priority number (RPN) in healthcare FMEA. The closest that healthcare comes to that is the hazards scoring matrix™ proposed by the VA (DeRosier J, Stalhandske E, Bagian J, Nudell T. Using health care failure mode and effect analysis: The VA national center for patient safety’s prospective risk analysis system. Jt Comm J Qual Improv. 2002 May; 8(5):248-67. 

Q. Do you think the person who is working in the healthcare area should be a doctor; or maybe an engineering background is better?

A. I think we need both. I think that good design of processes and mistake-proofing devices requires teamwork and insights from a variety of viewpoints. In addition to doctors and engineers, I would recommend including the viewpoints of nurses, medical technicians, and anyone else who participates in the process.

Q. Do you have any examples from chemo injection mistake proofing?

A. I do not, but I am constantly looking for more examples in healthcare. If you know of examples of mistake-proofing from chemo injection processes, please share them with us by e-mailing them to jgrout@berry.edu.


For More Information:

 Download John Grout’s book Mistake-Proofing the Design of Health Care