03 - Mistake Proofing

Shari Welch, MD, FACEP

The emergency department is the site for more and varying treatments, processes and procedures than any other real estate in your healthcare institution. Unfortunately the emergency department is also the most frequent location for death and disability related to inefficient care and a frequent site of adverse events in medicine, according to the Joint Commission. The ability to maintain quality control and patient safety for this vast myriad of activities is increasingly an unachievable goal. As other industries have appreciated, we need to design our work environment to prevent errors, to recognize and alert the team when an error has occurred and to reduce the effects of user errors. This is a monumental task, and one that deserves our effort.

Mistake proofing is the use of process or design features to prevent errors or prevent the negative impact of those errors. Mistake proofing is also known as poka-yoke (pronounced poka-yokay), Japanese slang for "avoiding inadvertent errors". Nowhere has this concept been built out and systematized better than at Toyota under the mistake-proofing guru, Shigeo Shingo (Shingo 2). Mistake proofing was formalized by Japanese manufacturers in the 1960’s and translated into English in the 1980’s. But mistake proofing is older than that. The Otis elevator brake which stopped the elevator between floors when a cable broke, was introduced in the 1850’s. In that example the elevator cable could still sever or disconnect, but the Otis brake allowed the elevator operator to mitigate the damage by stopping the elevator mid-floor.

Another example of mistake proofing involves the everyday filing cabinet. The early cabinets would tip over if more than one filing cabinet drawer filled with heavy files, was open at a time. The mistake proof design has one open drawer lock the others closed to prevent tipping. Another early example of mistake proofing can be seen in the design of this early medicine bottle. From the 19th century, this bottle was deliberately designed with tactile spikes. In this way the doctor, nurse or patient was alerted to the fact that a dangerous compound was inside. Human creativity and ingenuity have been used in the environment to prevent or mitigate the mistakes that humans will make. It is high time such efforts took off in our work environment. IMAGE HERE.

How about a Pyxis® or medication dispensation system that alarms if we try to open the drawer of a medication that the patient is allergic to?