Mistake-Proofing In Medicine, And In Refrigerators

Cheryl Clark, for HealthLeaders Media , October 21, 2009

Here are three tips gleaned from the report, but there are hundreds of others.

  • Keep items commonly used in plain sight, and remove items that are rarely used, or for which usage requires more skill, preparation, or knowledge.
  • Keep standard operating procedures as simple as possible. The more complex the rules and procedures, the more there exists the chance for errors. "Design changes can prevent mistakes by simplifying or clarifying the work environment, making mistakes less likely," the report says.
  • Instill a blame-free culture that values accountability, but that allows people to report errors and question processes without fear of retribution or punishment. "A policy of not blaming individuals is very important to enable and facilitate event reporting, which in turn enables mistake-proofing.

The document provides numerous examples of thoughtful mistake-proofing to prevent potentially lethal mistakes.

For example, a prescription filling area at a Norfolk, VA, hospital is marked by red line barrier, indicating a quiet, no interruptions zone for pharmacy workers needing to concentrate in silence. After it was instituted, dispensing medication errors fell by 64%.

A new breed of radiation machine in use at Elbert Memorial Hospital in Georgia can detect the amount of radiation that has penetrated a patient. It automatically terminates exposure when a predetermined level has been reached.

X-ray detectable sponges are increasingly used in surgical settings because when they are left in muscle or fat tissue, they can be easily detected.

A wristband checklist in use at Virginia Mason Medical Center in Seattle uses symbols to show whether heart attack patients have received widely-accepted treatment regimens. Patients can't be discharged until all their wristband records are checked.

And Target has begun using a flat pill bottle that is color-coded and allows flat rather than rounded sides to allow the name of the medication to be more easily read, and so drugs intended for one family member aren't mistakenly taken by another.

The era of the error failure system is here. And clearly more solutions are coming from creative problem solvers.

Maybe they have an idea for a better system to alert when the refrigerator door is left open too long, too.

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