Poka-Yoke in Healthcare : A Moral Obligation

Poka-Yoke is a Japanese term coined in the 1960s by Shigeo Shingo. The term essentially means “Mistake Proofing”. He found that you could dramatically reduce the amount of errors in factories by redesigning the process workers go through in the assembly line.

Some great examples of modern-day Poka-Yoke are:

-SIM cards (with the notch out of one corner)

-Needing your foot on the brake before you’re able to start your car

-Microwaves needing to be shut before they will turn on

But while Poka-Yoke was originally designed in automobile factories, it’s highest and best use might very well be in Healthcare. Mistakes are a massive problem in this industry and mistakes in healthcare have major consequences.

Mistakes lead to the $900B that is wasted in Healthcare every year. That’s 25% of all healthcare spending, thrown in the garbage...literally. And the problem doesn’t stop with waste...over 250,000 people die every year because of medical errors.

This problem is highlighted in the book “Checklist Manifesto”...

"Our great struggle in medicine these days is not just with ignorance and uncertainty. It's also with complexity: how much you have to make sure you have in your head and think about. There are a thousand ways things can go wrong."

This is precisely why Poka-Yoke is so important in our industry.

Those of us who serve the healthcare community should feel a moral obligation to not only build products that are useful and effective, but ones that help our users make less mistakes.

But one of the reasons why Poka-Yoke is so hard to implement is that you have to understand the process really well in order to mistake-proof it.

That’s exactly why we spent 3 years beta testing PREFcards? in the OR before we brought it to market. It was in this testing process that we found that there are 10 key moments in time where nurses, scrub techs and surgeons are more likely to make mistakes.

By understanding the context around these moments in time, we were able to build in barriers. The result? PREFcards? users simply make less mistakes.

So the question for you is this... What are you doing to mistake proof your product? Do you know the process your users go through well enough to predict when things can go wrong? If not, let this be a wake up call.

And if you’re in the healthcare industry, that wake up call should be extra urgent...

People’s lives depend on it.