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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.

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.

Select to download print version PDF file (PDF File, 1.6 MB).

By John Grout, Ph.D., Berry College, Rome, GA



Chapter 1. What is Mistake-Proofing?
   Mistake-Proofing Defined
   A Review of Human Error
   Mistake-Proofing Approaches
   Attributes of Mistake-Proofing
   Creating Simplicity Is Not Simple
   Implementing Mistake-Proofing in Health Care
Chapter 2. Relationships to Existing Patient Safety Efforts and Tools
   Relationships to Existing Patient Safety Efforts
   Knowing What Errors Occur and Why Is Not Enough
   Using the Tools Together
Chapter 3. How to Mistake-Proof the Design
   The Design Change Imperative
   Multiple Fault Trees
   Designing Mistake-Proofing Devices that Cause Benign Failures
   An Application Example
Chapter 4. Design Issues, Caveats, and Limitations
   Mistake Proof the Mistake-Proofing
   Avoid Moving Errors to Another Location
   Prevent Devices from Becoming Too Cumbersome
   Commit the Appropriate Resources
   Avoid Type I Error Problems
   Avoid Unintended Utilization of Benefits
   Prevent Worker Detachment from the Process
Chapter 5. Examples of Alternative Approaches to Mistake-Proofing
   Example Set 5.1—One Exposure Only, Please
   Example Set 5.2—Variations in Scald Prevention
   Example Set 5.3—Medical Gas Connections
   Example Set 5.4—More Connections
   Example Set 5.5—Variations in Tube Identification
   Example Set 5.6—Variations in Esophageal Intubation Detection
   Example Set 5.7—Variations in "Take Your Medicine," Part I
   Example Set 5.8—Variations in "Take Your Medicine," Part II
   Example Set 5.9—Variations in "Take Your Medicine," Part III
   Example Set 5.10—Examples from the Built Environment, Part I
   Example Set 5.11—Examples from the Built Environment, Part II
   Example Set 5.12—Examples from the Built Environment, Part III
   Example Set 5.13—Getting X-Rays Right
   Example Set 5.14—Exposure Control
   Example Set 5.15—Bed Alarms and Fall Reduction
   Example Set 5.16—Sharps
   Example Set 5.17—Controlling the Controls
   Example Set 5.18—Software
   Example Set 5.19—Refrigeration Feedback
   Example Set 5.20—Mistake-Proofing Patient Interactions
   Example Set 5.21—Wristbands
Chapter 6. Medical and Nonmedical Examples: Differences and Similarities
   Example Pair 6.1—Color Coded Wires
   Example Pair 6.2—Automatic Wheelchair Brakes
   Example Pair 6.3—Picking Up the Right Product, Part I
   Example Pair 6.4—Picking Up the Right Product, Part II
   Example Pair 6.5—Close the Door to Start
   Example Pair 6.6—Push to Go
   Example Pair 6.7—Collision Prevention
   Example Pair 6.8—What Goes In Must Not Come Out
   Example Pair 6.9—Two Hands Required
   Example Pair 6.10—How Information Is Presented Matters
   Example Pair 6.11—Tooling: Jigs and Fixtures
   Example Pair 6.12—Lock-Outs
   Example Pair 6.13—Visual Indication of Settings
   Example Pair 6.14—Knowledge in the World Equals Knowledge on the Pill
   Example Pair 6.15—Don't Reinvent the Wheel, Part I
   Example Pair 6.16—Coverage Must Be Complete
   Example Pair 6.17—Wheelie Bars
   Example Pair 6.18—Don't Reinvent the Wheel, Part II
   Example Pair 6.19—Color-Coded Lights
   A Future Mistake-Proofing Wish List
Chapter 7. Examples of Mistake-Proofing in Health Care
   Example 7.1—The Broselow® Tape for Pediatric Trauma
   Example 7.2—Finding the Chart in a Patient's Home
   Example 7.3—Labeling of Bottled Breast Milk
   Example 7.4—Ensuring that Time-Outs Occur
   Example 7.5—Look-Alike and Sound-Alike Medications
   Example 7.6—"Tall Man" Labels
   Example 7.7—High-Risk Medicine Cues
   Example 7.8—The Bloodloc™
   Example 7.9—Child Scale
   Example 7.10—A Safer Blood Pressure Cuff
   Example 7.11—Sign Your Site
   Example 7.12—Templates
   Example 7.13—High Risk Medications
   Example 7.14—Emergency Defibrillator
   Example 7.15—The 5 Gauss Line
   Example 7.16—More Color-Coding
   Example 7.17—Leave Me Alone, I Have to Concentrate
   Example 7.18—What Is Normal?
   Example 7.19—Automatically Terminated
   Example 7.20—Blood Sample Traceability
   Example 7.21—Leave that Stopper in Place
   Example 7.22—Oral Syringes: Two for One
   Example 7.23—Newborn Resuscitation
   Example 7.24—X-Ray-Detectable Sponges
   Example 7.25—Anti-Reflux Valves
   Example 7.26—Wristband Checklist
   Example 7.27—Time to Re-Stock
   Example 7.28—Knowledge on the Bottle
   Example 7.29—Weaving Tangled Webs
   Example 7.30—What's the Status?
Chapter 8. More Examples of Mistake-Proofing in Health Care
   Example 8.1—Infant Abduction Prevention
   Example 8.2—Bar Coding
   Example 8.3—Computer-Aided Nutrition and Mixing
   Example 8.4—Equipment Collisions
   Example 8.5—Flawless Equipment Setup
   Example 8.6—Mistake-Proof Mistake-Proofing
   Example 8.7—Private Files
   Example 8.8—Computer Drug Interaction Checker
   Example 8.9—Computerized Physician Order Entry
   Example 8.10—Sponge-Counter Bag
   Example 8.11—Notebook Switches
   Example 8.12—Plug Protection
   Example 8.13—Instructions Getting in the Way
   Example 8.14—Monitoring Glucose
   Example 8.15—Unit Dosing
   Example 8.16—Kits
   Example 8.17—Bacteria-Detecting Bandages
   Example 8.18—Urinalysis Test Strips
   Example 8.19—Controlled by Connections
   Example 8.20—Child-proofing
   Example 8.21—Hemoglobin Testing
   Example 8.22—Auto Shut-Off Treadmills
   Example 8.23—Visual Systems
   Example 8.24—Needleless Systems
   Example 8.25—Dress Code Cued by Floor Tile
   Example 8.26—Internet-Aware Refrigerator
   Example 8.27—Resources with Which to Err
   Example 8.28—Keeping Time
   Example 8.29—Distinct Labeling
   Example 8.30—Free-Flow/No-Flow Protection
Chapter 9. Summary
   Example Summary
   Sources of Supply
   Industrial Glossary
   A Path Forward
   Example Contributions

AHRQ Publication No. 07-0020

Page last reviewed May 2007
Internet Citation: Mistake-Proofing the Design of Health Care Processes. May 2007. Agency for Healthcare Research and Quality, Rockville, MD.