Mistake Proofing A quality tool to improve the care of our patients

INTRODUCTION:

Mistake proofing is an old tool formalized by Shigeo Shingo from Toyota motors which contributed in what is called nowadays the ‘Toyota Production System’ that is synonymized with ‘Quality’. The tool is used to reduce occurrence of errors, make errors hard to occur unnoticed, easy to correct errors before they can cause serious harm, and let the system fail safely when it fails. Healthcare is a risky industry and the mistake proofing tool is a good technique that was used from automobile industry to improve quality and patient safety.

CASE PRESENTATION

Mistake proofing uses changes in the physical design of processes to reduce human error. It can be used to change designs in ways that prevent errors from occurring, to detect errors after they occur but before harm occurs, to allow processes to fail safely, or to alter the work environment to reduce the chance of errors. Effective mistake proofing design changes should initially be effective in reducing harm, be inexpensive, and easily implemented. Over time these design changes should make life easier and speed up the process. Ideally, the design changes should increase patients' and visitors' understanding of the process.

CONCLUSION

The PSIC team felt that it was important to be able to determine whether the bed was at the correct angle from outside the room in the ICU. Their solution was to apply a label to the bed to indicate the correct angle (fig 33).). The label is easily made and installed, but requires a judgment call on what 30° looks like.