| Direction | Relationship | Comment |
|---|---|---|
| Safety culture | Enabler | Efforts to shape the norms and values of an organization to focus on creating safety-conscious behaviors and to commit significant organizational resources to achieve patient and worker safety. |
| Just culture | Enabler | A subset of safety culture. Provides an open environment—one in which errors are viewed as opportunities to learn rather than events to be punished—which encourages increased event reporting. |
| Event reporting | Enabler | Disclosing adverse events and errors that need remedial action to prevent them in the future. |
| Root cause analysis | Enabler | Identifies causes "that we can act upon such that
it meets our goals and objectives and is within our
control."2 Mistake-proofing cannot be done without a clear knowledge of the cause and effect relationships in the process. |
| Corrective action systems | Area of opportunity | Policies and procedures that ensure causes of events are properly resolved and remedial actions are taken. |
| Specific foci | Area of opportunity | Those efforts in which the special focus is on particular outcomes or events, including falls, nosocomial infections, medication errors, and wrong-site surgery. |
| Simulation | Area of opportunity and venue for validation | Builds correct, conditioned responses; provides a laboratory for identifying and validating the effectiveness of mistake-proofing projects. |
| Technology | Subset | Includes bar coding, computerized physician order entry (CPOE), and robotic pharmacies; expensive, complex, more technologically sophisticated version of mistake-proofing. |
| Facility design | Complementary or a subset | Using building layout and design to put knowledge in the world is effective but difficult with large, long-lived existing infrastructure. |
| Revise standard operating procedures (SOPs) | Competing or complementary | Choosing to lengthen SOPs or increase their
complexity is an easy but often ineffective
alternative to mistake-proofing. Simplifying processes and providing clever work aids can complement or border on being mistake-proofing. |
| Attention management | Competing (partially) | Mistake-proofing can reduce the need for some aspects of attentiveness; it frees staff members to attend to more important issues that are more difficult to mistake-proof. |
| Crew resource management (CRM) | Complementary | Some mistake-proofing devices reduce the need to attend to process details. This reduced cognitive load can free resources and facilitate effective participation in decisionmaking typical in CRM. |
| Failure modes and effects analysis (FMEA) or failure modes, effects, and criticality analysis (FMECA) | Area of opportunity design tool | FMEA and FMECA identify and prioritize improvement efforts. Effective FMEA requires actions that lead to redundancy or mistake-proofing. |
| Fault trees/probabilistic risk assessment | Area of opportunity design tool | Identify all known causes of an event and the probabilities of their occurrence. This is vital information in creating informed design decisions about mistake-proofing devices. A non-traditional application of this tool is presented in Chapter 3. |