Mistake-Proofing the Design of Health Care Processes

Preface

It has been more than 7 years since the Institute of Medicine (IOM) released its landmark report, To Err Is Human: Building a Safer Health System, which galvanized attention on the serious and pervasive problem of errors in health care.

Research into the causes of medical errors and ways to prevent them increased dramatically in the ensuing years after publication of the IOM report in 1999. We certainly have made great progress, but we still have much more to do to improve patient safety at all levels of our health care system.

The Agency for Healthcare Research and Quality (AHRQ) has been involved in research on patient safety and medical errors for many years. This publication is the latest in a long line of AHRQ-sponsored resources devoted to patient safety. It sheds light on a little-known but very promising approach to preventing medical errors and reducing the adverse outcomes that result from them.

Mistake-Proofing the Design of Health Care Processes was compiled for AHRQ by John Grout, Ph.D., of Berry College in Rome, GA. Dr. Grout has been working for many years to disseminate information about the use of mistake-proofing devices in health care. This volume represents a compendium of information and ideas to broaden our understanding of mistake-proofing and its emerging role in health care and patient safety.

Our hope is that the information and resources presented in this publication will lead to more and better error-prevention efforts in our Nation's hospitals, medical offices and clinics, laboratories, and residential care settings. Mistake-proofing has great potential as a quality improvement tool. It has been successfully applied over many years in industry, and many mistake-proofing devices are already being used to improve health care here in the United States and in other countries.

We have only scratched the surface, however; as many other devices and applications are still in the pipeline or have yet to be discovered and disseminated. We thank Dr. Grout for his hard work in putting together this excellent resource and for his dedication to improving the safety of health care in America.

We welcome your feedback on this publication. Comments and questions may be sent in writing to: AHRQ, Office of Communications and Knowledge Transfer, 540 Gaither Road, Rockville, MD 20850.

Carolyn M. Clancy, M.D.
Director
Agency for Healthcare Research and Quality

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