Poka-Yoke: changing designs to improve patient safety (1)

Patrice Spath wrote: “If healthcare is to improve patient safety, systems and processes must be designed to be more resistant to error occurrence and more accommodating of error consequence”.1

Senders and Senders wrote: “Errors will continue to be made. Accidents, on the other hand, can largely be prevented by intelligent and imaginative use of additional cues that announce that an error has occurred and that make it possible for the error to be corrected before damage has been done. Where possible, physical design should be used to prevent the error from being translated into injury.”2

Processes occur in a physical environment populated with equipment, supplies, devices, and technologies. This paper is intended to help generate ideas about how this physical environment can facilitate processes—how design changes can make processes, executed by humans within a physical environment, more reliable and effective. It is about how changing the?design?of processes can prevent the performance of a prohibited action, ensure required actions are performed, or ensure that information required for correct action is available at the correct time and place, and that it stands out against a noisy background. Creating such designs is called “mistake-proofing”. It is also known for its Japanese slang buzzword “poka‐yoke”. The ideas and impetus for design changes will not come solely from a single area of expertise; rather, all medical personnel, doctors, nurses, technicians, engineers, designers, managers, and executives need to think about how the design of healthcare processes could be improved.

Examples of mistake-proofing include “self‐blunting” sharps and the revolving door style lid of a sharps container that insulates its users from its hazardous contents. The pin indexing systems common in medical gas connections in many hospitals is another example. Mistake proofing would also include high-tech solutions like barcoding, automated medication dispensing systems, and electronic infant abduction detection systems. However, in the upcoming articles, we will discuss how to use mistake proofing to improve patient safety and minimize errors.

References

1.?Spath P L. Reducing errors through work system improvements. In: Spath PL, ed.?Error reduction in health care. Chicago: AHA Press, 2000202

2.?Senders J W, Senders S J. Failure mode and effects analysis in medicine. In: Cohen MR, ed.?Medication errors: causes, prevention, and risk management. Sudbury, MA: Jones and Bartlett, 19993.6