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Table 2-1

Mistake-Proofing the Design of Health Care Processes -

Table 2.1. How mistake-proofing fits into common patient safety improvement efforts

Safety cultureEnablerEfforts to shape the norms and values of an organization to focus on creating safety-conscious behaviors and to commit significant organizational resources to achieve patient and worker safety.
Just cultureEnablerA subset of safety culture. Provides an open environment—one in which errors are viewed as opportunities to learn rather than events to be punished—which encourages increased event reporting.
Event reportingEnablerDisclosing adverse events and errors that need remedial action to prevent them in the future.
Root cause analysisEnablerIdentifies causes "that we can act upon such that it meets our goals and objectives and is within our control."2

Mistake-proofing cannot be done without a clear knowledge of the cause and effect relationships in the process.
Corrective action systemsArea of opportunityPolicies and procedures that ensure causes of events are properly resolved and remedial actions are taken.
Specific fociArea of opportunityThose efforts in which the special focus is on particular outcomes or events, including falls, nosocomial infections, medication errors, and wrong-site surgery.
SimulationArea of opportunity and venue for validationBuilds correct, conditioned responses; provides a laboratory for identifying and validating the effectiveness of mistake-proofing projects.
TechnologySubsetIncludes bar coding, computerized physician order entry (CPOE), and robotic pharmacies; expensive, complex, more technologically sophisticated version of mistake-proofing.
Facility designComplementary or a subsetUsing building layout and design to put knowledge in the world is effective but difficult with large, long-lived existing infrastructure.
Revise standard operating procedures (SOPs)Competing or complementaryChoosing to lengthen SOPs or increase their complexity is an easy but often ineffective alternative to mistake-proofing.

Simplifying processes and providing clever work aids can complement or border on being mistake-proofing.
Attention managementCompeting (partially)Mistake-proofing can reduce the need for some aspects of attentiveness; it frees staff members to attend to more important issues that are more difficult to mistake-proof.
Crew resource management (CRM)ComplementarySome mistake-proofing devices reduce the need to attend to process details. This reduced cognitive load can free resources and facilitate effective participation in decisionmaking typical in CRM.
Failure modes and effects analysis (FMEA) or failure modes, effects, and criticality analysis (FMECA)Area of opportunity design toolFMEA and FMECA identify and prioritize improvement efforts. Effective FMEA requires actions that lead to redundancy or mistake-proofing.
Fault trees/probabilistic risk assessmentArea of opportunity design toolIdentify all known causes of an event and the probabilities of their occurrence. This is vital information in creating informed design decisions about mistake-proofing devices. A non-traditional application of this tool is presented in Chapter 3.

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Page last reviewed May 2007
Internet Citation: Table 2-1: Mistake-Proofing the Design of Health Care Processes -. May 2007. Agency for Healthcare Research and Quality, Rockville, MD.