Reducing Medical Error by Learning from Existing Examples

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Reducing Medical Error by Learning from Existing Examples of Mistake-Proofing John R. Grout Campbell School of Business Berry College, Mt. Berry, GA jgrout@berry. edu 706 -238 -7877

Mistake-proofing in healthcare • Human factors proponents: – “forcing functions should be implemented in health care. ” – “The remedy is in changing systems of work. The remedy is in design. ” (Berwick) • Actual examples tend to be scarce.

Mistake-proofing in healthcare • Collection of 148 examples • Examples of diverse approaches to mistake-proof common medical events • Examples of similar approaches to mistakeproofing medical and non-medical domains. • How examples fit frameworks proposed: – – Chase and Stewart, Shingo, Tsuda, Nakajo.

Methodological Challenges/Caveats • Convenience sample • Some contributors can “see” more devices than others • Filtered by my understanding of medical processes • Filtered by what I think are more “interesting” devices • Filtered by what I think is a mistake-proofing device.

19 th century example of mistake-proofing in healthcare

Diverse approaches to common medical events Portable Esophageal Intubation Detection

Diverse approaches to common medical events Take your medicine

Diverse approaches to common medical events Stay in bed

Diverse approaches to common medical events “Self-Blunting” Sharps

Diverse approaches to common medical events Connections Galore

Diverse approaches to common medical events Patient Interactions Blood donor interviewing CT exam breathing instructions

Similar approaches in medical and non-medical domains. Is medicine really all that different? • Unit of blood transfused in Mary Smith vs. Maria Smith • Package delivered to Wood Valley Ct. vs. Wood Valley Dr. …Only in terms of severity

See the difference? Medical solution Non-medical solution

Chase and Stewart Framework Customer Mistake-Proofing 41 of the 148 devices (27. 7%) Provider Mistake-Proofing 107 of the 148 devices (72. 3%)

Shingo Framework Setting function Regulatory function With enhancements by Chase & Stewart and Beauregard, Mikulak, & Mc. Dermott

Tsuda’s Framework

Nakajo’s Data Nakajo’s Framework

Make or buy

What’s ahead? • Hard work … • Few locally developed devices • Preliminary observations seem to indicate that healthcare FMEA’s are not leading to design changes, mistakeproofing, or human factors improvements.

Thank you! Questions?

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