Mistake
-
Proofing the Design of Health Care Processes
What Is Mistake
-
Proofing.
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.
Patients should experience health care processes that are more reliable than
manufacturing processes. Regrettably, that is not yet the case.
1
These are common errors. Their cons
equences 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
Orga
nizations (JCAHO)
2
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 execute
d 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 f
rom 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 thre
atening, 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
3
state that "techniques for designing safe processes are known, waiting
only to be adapted t
o 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
Mis
take
-
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
4
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
