Mistake proofing presentation

Effective Mistake-proofing for Healthcare:
Principles & Techniques for Sustained Improvement
Presented by:
Brian Nass BSEE, MSME, MSIE
Senior Advisor, Lean Advisors Inc
www.leanadvisors.com
1

Patient story
Copyright ©2013 Lean Advisors Inc.

• Highly-trained, highly-skilled caregivers
• Needs of the patient at the forefront
• Safety mechanisms in place
• Required resources on hand
What do these situations have in common?
Then why were there bad outcomes
for these patients, their families, and the
caregivers?

Read this sentence
FINISHED FILES ARE THE RE-
SULT OF YEARS OF SCIENTIF-
IC STUDY COMBINED WITH
THE EXPERIENCE OF YEARS.
How many Fs are there in the above sentence?
(Count them one time only)
The answer is……

Read this sentence
FINISHED FILES ARE THE RE-
SULT OF YEARS OF SCIENTIF-
IC STUDY COMBINED WITH
THE EXPERIENCE OF YEARS.
The answer is……6
How many Fs are there in the above sentence?
(Count them one time only)

Objectives
Understand what is meant by defect-free
philosophy
Understand why errors occur
Understand what is meant by mistake-
proofing and identify best mistake-proofing
strategies
Understand how consideration of human
factors can help in developing solutions for
improvement
Know what to do next and how to do it

Definitions
Mistake
› An error in intent, leading to a
wrong action
Slip
› An error in execution of an
action, even though the intent was
correct

Definitions
Process Defect
› An undesirable outcome
› Any instance of not meeting patient,
customer, institutional, or regulatory
requirements
› An un-necessary outcome
Defects are also a
category of WASTE.

Examples of defects
› Turn-around time beyond customer’s
expectation
› Wrong-site surgery
› Patient leaving ED without being seen
› Prescription filled incorrectly
› Patient dissatisfied with the food
› Lost specimen
› Any instance where we paid expedite
charges to mail something out
(e.g., used Fed Ex) when it wasn’t
necessary
Definitions

Defect-free philosophy
• While humans are error-prone, our processes
need not create defects
• Error- and defect-free processes are achieved
through improved process design

Mistake-Proofing Solutions
Prevention-based
› Senses an abnormality that is about
to happen and keeps it from
happening OR
› Keeps the process from moving
forward until all required elements
are present and correct
13

Mistake-Proofing Solutions
Detection-based
› Senses an abnormality once it
has occurred, highlights the
occurrence, so that corrective
action can take place at the point
of origin
14

Mistake-Proofing
Well-designed mistake-proofing solutions
(“devices”)…..
› Are devised by the people closest to the
work
› Prevent error
› Provide immediate feedback
› Compel countermeasure(s)
› Make it impossible to do the wrong thing
› Are simple and inexpensive

Examples from our daily lives
1
2
3
4
5

Mistake-proofing in common use in healthcare
17

Defects- “Triggers”
Latent Failures- “Resident Pathogens”
Observed defects
are a small part of
the larger picture of
human error
18

The Path
Figure out what’s
happening and
why
Remove as many
drivers of error that
you can
Design each task within
a process so that it is
hard to do the wrong
thing and easy to do the
right thing
Make your process
more robust against
errors (mistake-proofed)

It’s NOT About Assigning Blame…
It is natural for people to make mistakes
It is natural for people to miss a defect
It is natural for people to not notice…
› an IV pump malfunctioning
› dosing calculation not quite right
› vital signs that are incorrect
› equipment alarming

Berwick on Humans and Error
“...We are human and humans err. Despite
outrage, despite grief, despite experience, despite our
best efforts, despite our deepest wishes, we are born
fallible and will remain so. Being careful helps, but it
brings us nowhere near perfection... The remedy is in
changing systems of work. The remedy is in design. The
goal should be extreme safety. I believe we should be as
safe in our hospitals as we are in our homes. But we
cannot reach that goal through
exhortation, censure, outrage, and shame. We can reach
it only by commitment to change, so that normal, human
errors can be made irrelevant to outcome, continually
found, and skillfully mitigated.”
Berwick DM. Not again! BMJ 2001;22:247-8.

Where Does Human Error Commonly Come From?
Deficits of
› Attention
› Working memory
› Decision making
Our strong pattern recognition
Similarity between different tasks
“Automaticity” in task performance
Weakened mental or physiological state

THE PAOMNNEHAL PWEOR OF THE
HMUAN MNID
“I cdnuolt blveiee that I cluod aulaclty uesdnatnrd what I
was rdgnieg.
Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it
deosn't mttaer in what oredr the ltteers in a wrod
are, the olny iprmoatnt tihng is that the first and last
ltteer be in the rghit pclae. The rset can be a taotl mses
and you can sitll raed it wouthit a porbelm. This is
bcuseae the huamn mnid deos not raed ervey lteter by
istlef, but the wrod as a wlohe.
Amzanig, huh?”
What are the implications of this?

Human Factors
The study of human capabilities and
limitations
› How we think
› How we act/ What we do
› What we use to do it

Human Factors Triangle
COGNITION
TASKTOOLS
How do we make decisions?
How do we learn?
How does our attention work?
How do we multi-task?
What is the nature of the task?
How do we know what to do next?
What influences our ability to do it?
Do we understand what successful
task execution looks like?
What tools are we given?
How easy or difficult are they to use?
What is their efficacy?
How do we know if they
are used correctly?

When should I go??

Mistake-Proofing Priorities
1. Eliminate - remove step from process
2. Prevent - eliminate root causes of error
3. Detect - detect when error
occurs, enabling immediate correction
at the point of occurrence
4. Manage – contain defects within the
process before they reach the
customer/patient
BEST!

How to proceed
Where are defects
produced and what errors
lead to each?
At what process step
does each error
originate?
What is the nature
of the errors (or
combinations)?
Perform root cause
analysis to uncover
combinations of factors
leading to error
Design your mistake-
proofing “device”
Estimate its strength
Try it outMeasure the results
Determine how
your “device” could
be made stronger

Assessing Efficacy of the “Device”
• Is it automatically triggered?
• Does it prevent wrong actions?
• If not preventive, does it shut down the process?
• If not a shut down, does it effectively alarm the
person making the error?
• To what extent can people create work-arounds?
• To what extent can we sustain this “device”?
• How feasible is this to implement?

Mistake proofing example:
Reducing CLABSI (dramatically)

1. Slap on the wrist (or warning thereof)
2. Re-training
3. Double checks
4. Replace the person(s) with others with more
experience/skill
5. Add technology to the process step/activity
6. Add more staff
Caution: watch out for these
common “interventions”
What is the efficacy of the above?
What issues do you see with the above?

Separate handouts provided:
1. “Red Flag” conditions
2. Reading list
3. Double checks: design guidelines
Thank you!

Frequently Asked Questions
Contact US:
877-778-6413
corp@leanadvisors.com
www.leanadvisors.com

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