Error Proofing Basics
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Transcript of Error Proofing Basics
8/12/2019 Error Proofing Basics
http://slidepdf.com/reader/full/error-proofing-basics 1/16
Lean Education
Error Proofing
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The tool What is it?
What’s it for?
How does it work?
When do you use it?
What’s an example?
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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: Bui lding a Safer Health System,
Institute of Medicine (IOM)
Read for Free at: http://www.nap.edu/books/0309068371/html/
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Error Proofing – Is it Needed?
The New York Times Magazine, March 16, 2003
Kidney
Transplant
wrong side
Unnecessary
radical jaw
surgery
Surgicaltool left in
stomach
Surgicalsponge and
gauze left in
breast
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Error Proofing – Is it Needed?
CNN, November 21, 2007
OLD
NEW
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How does it work? Weaknesses in processes are identified
by observation, measurement, or other
methods
Ideas for eliminating errors arecollected, evaluated, and tested
The most effective and practicalsolution(s) are implemented
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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 ofcorrection
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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
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More Error Proofing Examples
http://mmpp.wikispaces.com/
NG tube cannotbe connectedto an IV port
Yellow tubing isattached to all
epidural meds andserves as a visual
indicator
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Error Proofing in Practice
ER: Pyxis-for all criticalsupplies; not just for
drugs
Lab: Barcode scanner wasimplemented to scan and identifyspecimens quickly and without
errors.
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Sanjay Saint, MD, Univ. of Michigan Healthcare System implementeda 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 Highl ights Newsletter
Read for Free at: http://www.bcbsm.com/foundation/pdf/05highlights.pdf
Error Proofing in Practice