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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

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Questions?