lean education error proofing. the tool what is it? what’s it for? how does it work? when do you...
TRANSCRIPT
Lean Education
Error Proofing
The tool
What is it? What’s it for? How does it work? When do you use it? What’s an example?
What is it?
Error Proofing is a method of identifying ways to eliminate or reduce errors in a process
There are multiple levels of solutions Level 1 – total elimination Level 2 – reduction of error rate
(when elimination not possible)
Error Proofing – Is it Needed?
“Between 44,000 and 98,000 people die each year nationwide as a result of avoidable errors in hospitals… Safety does not reside in a person,
device or department, but emerges from the interactions of components of a system.”
Errors can include problems in practice, products, procedures and systems. The usual responses to such errors focus on preventing
recurrence by punishing or retraining individuals. These responses tend to be ineffective because they ignore the system and instead focus
on one particular set of circumstances that are unlikely to reoccur.
To Err is Human: Building a Safer Health System,Institute of Medicine (IOM)
Read for Free at: http://www.nap.edu/books/0309068371/html/
Error Proofing – Is it Needed?
The New York Times Magazine, March 16, 2003
Kidney Transplant wrong side
Unnecessary radical jaw
surgery
Surgical tool left in stomach
Surgical sponge and gauze left in
breast
Error Proofing – Is it Needed?
CNN, November 21, 2007
OLD
NEW
How does it work?
Weaknesses in processes are identified by observation, measurement, or other methods
Ideas for eliminating errors are collected, evaluated, and tested
The most effective and practical solution(s) are implemented
When do you use it?
When errors are identified and are causing a process to be inefficient
When harm is coming to patients, regardless of frequency or difficulty of correction
Error Proofing
Process for avoiding simple human errors:
• Makes Zero Defects possible• Eliminates need for additional inspections• Shows respect for intelligent workers• Frees a worker’s time and mind to pursue creative, value-adding activities
Attitude: It is NOT acceptable to produce even a small number of defects
Outlets for various types of gases are “keyed” in such a way that wrong connections can not be made. All connectors have a pin at the 12 o’clock position, but differ on the second position.
Credit to John Grout, Berry College, www.mistakeproofing.com/medical
Level 1: Total PreventionDefect cannot be made
Level 2: Color
Coding
Level 1: Keying
“Condition H” (Shadyside, Patient/Family call for RRT
Error: esophageal intubation (putting a tube into a patient’s stomach which was intended for their lungs)
Error proof: Squeeze bulb and put on tube. If bulb inflates, the tube is in the lungs. If not, tube is incorrectly placed in the esophagus.
Level 1: Total PreventionDefect cannot be made
Credit to John Grout, www.mistakeproofing.com/medindex.html
Level 2: Hand Washing Before Entry
Kevin Frieswick at MetroWest Medical Centerhttp://www.leanblog.org/2009/04/leanblog-podcast-65-error-proofing/
“Stop”/Go Arm is UpLight Sensor under Sanitizers – both inside room and out – raises the “Stop” arm
More Error Proofing Examples
http://mmpp.wikispaces.com/
NG tube cannot be
connected to an IV port
Yellow tubing is attached to all
epidural meds and serves as a visual
indicator
Error Proofing in Practice
ER: Pyxis-for all critical supplies; not
just for drugs
Lab: Barcode scanner was implemented to scan and identify specimens quickly and without errors.
Sanjay Saint, MD, Univ. of Michigan Healthcare System implemented a reminder system for physicians to remove the urinary catheters of hospitalized patients.
• Indwelling urinary catheters are placed in ~25% of hospital patients.• Estimated 40% of infections developed during hospital stay are urinary
tracts infections, most due to urinary catheters.The reminder system error proofs the process by helping the doctor know which patients have catheters, how long they have been in, and when to order removal. Study results showed that each patient’s hospital stay that involved a catheter went down by 7.6% on the “reminder” wards. And, the written-reminder system isn’t expensive.
Dr. Sanjay Saint UMHS in BCBSM’s Highlights Newsletter
Read for Free at: http://www.bcbsm.com/foundation/pdf/05highlights.pdf
Error Proofing in Practice
Questions?