Agency News and Notes

New resource offers suggestions for improving the safety in health care environments

The Agency for Healthcare Research and Quality (AHRQ) recently released a new resource of mistake-proofing tools, examples, and practical applications to help providers improve the delivery of care within their settings. The resource is titled Mistake-Proofing the Design of Health Care Processes.

Tips for simple and inexpensive mistake proofing, leveraging the benefit of root causes analysis, and creative methods for using non-medical products in health care environments are highlighted.

Specific examples include:

• Marking floors to delineate quiet zones that reduce interruptions to nurses that could result in medication errors.
• Using a pen, microchip, and wristband to minimize the chances of wrong-site surgery.
• Attaching chemical light sticks to intravenous tubes for fluid identification.

Written by AHRQ researcher John Grout, Ph.D., newly appointed dean of Berry College's Campbell School of Business, this resource is a helpful reference point for those responsible for delivering care and for those who instruct or coach others that deliver care.

Mistake-Proofing the Design of Health Care Processes includes 150 examples, most with photographs, and is now available online at http://www.ahrq.gov/qual/mistakeproof.

In addition, AHRQ's Healthcare 411 audio podcast features comments on mistake-proofing in health care from Dr. Grout at http://healthcare411.ahrq.gov/.

You can listen to the audio program directly through your computer if it has a sound card and speakers and can play MP3 audio files, or you can download it to a portable audio device. In any case, you will be able to listen at your convenience.

Limited copies of the print version (AHRQ Publication No. 07-0020) or CD-ROM (AHRQ Publication No. 07-0020-CD) are available from the AHRQ Publications Clearinghouse.

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