Chapter 5. Examples of Alternative Approaches to Mistake-Proofing
Introduction
As discussed in Chapter 1, mistake-proofing can use a
variety of setting functions, control functions, or
categories. This chapter provides 67 examples of mistake-proofing
organized into 21 sets. Each set highlights
alternative approaches to similar problems. Since each
organization's processes are subtly but distinctly unique,
different organizations can use a variety of related
approaches to address specific situations.
The inclusion of the examples in this chapter follows the
pattern of books on mistake-proofing in
manufacturing.1,2,3,4 Some of these examples will be directly
applicable to errors that confront organizations. Others
might suggest how to approach a novel problem that is a
source of concern. The following are issues for
consideration as the mistake-proofing examples in this
chapter are discussed:
- Consider the most appropriate circumstances for each mistake-proofing example.
- Consider whether processes have adequately addressed issues raised by the examples.
Pella Window engineers develop and test seven solutions
before identifying and implementing the best one.
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Example Set 5.1—One Exposure Only, Please
Unintentionally exposing x-ray film to light destroys
images that are vital to proper patient care. These images
can usually be recreated, but they cost time and money.
The entrance to the hospital darkroom door (Figure 5.1)
has only one opening in a revolving drum. Passing
through the vestibule ensures that the contents of the
darkroom are not unintentionally exposed. The door
creates a failure in that you cannot enter the darkroom
under incorrect conditions.
Figure 5.2 shows a film bin equipped with a special
locking mechanism. The mechanism includes a light
sensor that will not allow the bin to be opened when light
is present in the darkroom.
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Example Set 5.2—Variations in Scald Prevention
Data from the National Safe Kids Campaign indicate that
4,000-5,000 children are scalded each year, receiving
third-degree burns that cover at least 12 percent of the
body.5 Most of these events do not take place in medical
facilities, although fatalities have occurred in medical
facilities. Listed below is a variety of devices designed to
reduce the chance of scalding.
Figure 5.3 illustrates a device that uses color-changing
plastics to warn when water reaches dangerous
temperatures, and scalds can occur.
The color of the circular ring changes from purple (left) to
pink (right) when water exceeds 40°C, 104°F. A
triangular ring (not shown) changes at 37°C.
The anti-scald plug shown in Figure 5.4 works the same
way as the circular ring, but with one crucial difference:
the anti-scald plug, by requiring the user to place the
device in order to fill the tub, enforces its own use. In
other words, the user must use the device to fill the tub,
and using the device prevents scalding.
The anti-scald valve in Figure 5.5 is attached to the end of
a faucet. It contains a valve that closes when water reaches
117°F. This device is easy to install. It is simply threaded
on to the end of the faucet, replacing the standard filter or
aerator. It creates a "shutdown" that prevents the
possibility of scalding. This device lacks an override valve
that is available on some models. A valve would allow
hotter water to be obtained, if necessary, without
disassembling part of the faucet.
The device in Figure 5.6 is inserted into the end of the
shower pipe and works much like the previous device. It
also contains a valve that closes when water becomes too
hot. This device installs in a few minutes using an Allen
wrench and is completely hidden once installed.
The device in Figure 5.7 is a thermostatic mixing valve. It
provides "forced control" by automatically mixing cold
water with hot water to reduce the water temperature. The
maximum water temperature can be set and adjusted.
Installation of this type of valve is more troublesome than
the other devices mentioned here. In some cases, the
mixing valve is located behind the wall of the shower, and
installation or adjustment requires carpentry and
plumbing.
The devices in Figures 5.5, 5.6, and 5.7 require regular
maintenance for reliability and calibration.
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Example Set 5.3—Medical Gas Connections
Figure 5.8 illustrates the extensive mistake-proofing that
medical gas tanks undergo. Here, the fittings that connect
medical gases from the tanks in the back room to the
tubes leading to the patient have undergone extensive
mistake-proofing.
Tanks display the color-coding scheme. The color coding
serves as a "sensory alert" to ensure that the correct
connections are made between the tanks and the valves in
the patients' rooms. The tanks are also fitted with pin-indexed
connectors to prevent incorrect connections.
The generic regulator in Figure 5.9 has a dial that
indicates how many liters of oxygen are delivered. The dial
clicks as each liter of oxygen is delivered. Hinckley2 points
out that converting adjustments to settings is a very
powerful type of mistake-proofing because it requires far
less attention to detail and can accelerate the process
dramatically.
In this case, however, the design has a drawback which is
indicated in a warning box in the instructions: "There is
NO FLOW between settings. To obtain the desired
oxygen flow, the indicating pointer must point to a
specific number on the dial."6 Eliminating the possibility
of one mistake can create an opportunity for another.
...a physician treating a patient with oxygen set the
control knob to between one and two liters per
minute, not aware that the numbers represented a
discrete rather than a continuous setting. No oxygen
was flowing through, yet the knob rotated smoothly,
giving the suggestion that the intermediate setting of
the machine was possible. The patient became
hypoxic before the error was discovered. A design
solution would have been a rotary control that snaps
into a discrete setting along with some indication of
flow.7
If the probability of the second mistake is lower than the
probability of the first, on average, patients will benefit.
Designing the device so that flow continues at the rate of
the last setting, regardless of whether or not the indicator
sits between settings, might be safer.
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Example Set 5.4—More Connections
Often, connections are pin-indexed and color-coded. In
Figure 5.10, the holes for the pins for medical air are
located at 12 o'clock and 5 o'clock. Using this system, all
of the gases have a pin at 12 o'clock. The other pin is
different for each gas.
In their new facility in West Bend, WI, St. Joseph's
Hospital has gone further by standardizing the location of
each gas outlet on the head wall. Each gas outlet is located
in the same place on each head wall in the hospital.
How much color-coding is too much? In this case (Figure 5.11), the clear nozzle may be the most mistake-proof choice.
It is not possible to mount the nozzle on the wrong
regulator because it is universal, not color-coded. If you
have to stock yellow, green, and every other colored nozzle
in each location where they may be used, you not only
incur additional inventory costs, you may actually cause
reportable violations of operating policies or procedures
that would be impossible if only clear nozzles were
stocked.
Errors occur where things are almost the same but are
subtly different. What can be made identical should be.
What cannot be made identical should be made obviously,
even obtrusively, different (Figure 5.11).
The regulator in Figure 5.12 is attached to the wall with a
vinyl-covered steel cable in order to avoid converting the
regulator into a projectile that flies across the room when
it is disconnected under pressure. This is an example of
what Tsuda8 refers to as "preventing the influence of
mistakes."
The tubing can attach to a regulator with (Figure 5.13A)
or without (Figure 5.13B) the nozzle attached. If either
option is acceptable, this design is mistake-proof. If one
option is preferred, the design should be avoided.
The tubing can attach to a regulator with or without a
nozzle attached.
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Example Set 5.5—Variations in Tube Identification
Ensuring that labels on samples and test tubes are correct
is a very important aspect of reducing medical errors.
Often, printed labels with complete information are not
available at the bedside and must be retrieved from the
nurses' station. This delay can contribute to the
introduction of errors into the system. The following three
examples represent approaches to accurately identify tubes
and samples.
When multiple tubes are drawn at the same time, writing
a label for each can be time-consuming. The Bloodrac™
is produced by the makers of the Bloodloc™ (Chapter
7, Example 7.8). It enables several tubes to be stored
together with one handwritten label. The identification is usually the patient's name and the Bloodloc™ code on the patient's wristband.
Another approach to reducing the effort required to
accurately label multiple tubes is the use of a wristband
with pre-printed, peel-off, self-adhesive labels (Figures 5.14 and 5.15).
All the labels have the same unique identification
number. As they are removed, the same number appears
underneath each label.
These labels temporarily label the tubes until permanent
labels containing complete information can be printed and
affixed. Error rates are reduced because the preliminary
labels are only available at the patient's bedside.
Although the tube in Figure 5.16 receives the temporary
label with little chance of error, the possibility of errors
occurring when matching permanent labels with
temporary ones would also need to be addressed in the
process.
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Example Set 5.6—Variations in Esophageal Intubation Detection
Esophageal intubation is a common error that occurs
when the intubation tube is inserted in the patient's
esophagus instead of in the trachea. There are several
approaches to detecting this error in hospital settings.
Figures 5.17-5.21 illustrate a variety of low-tech
approaches that could be employed where power
requirements or space prohibit more sophisticated
approaches.
After the patient is intubated, a staff member squeezes the
bulb (Figure 5.17) and places it over the end of the tube.
If the bulb fails to re-inflate to its original shape, the tube
is in the esophagus. If it re-inflates fully, the tube is placed
correctly.
The bag in Figure 5.18 has a detector that changes color
in the presence of carbon dioxide. If the detector fails to
change color, then the tube is in the esophagus. If it
changes color, the tube is in the trachea. If the mistake-proofing
device fails, the device will indicate a situation
requiring corrective action.
The round cylinder at the end of the tube in Figure 5.19
is a whistle. As the patient breathes in and out the whistle
makes an audible, wheezing sound. The staff can hear the
patient's breath.
The device in Figure 5.20 is essentially a large caliber
syringe, but instead of pushing fluids out, it pulls in
anything available. If the plunger cannot be pulled out
easily, or if stomach contents come out, the tube is in the
esophagus. If the plunger pulls out easily and completely,
the tube is in the trachea as it should be.
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Example Set 5.7—Variations in "Take Your Medicine," Part I
The following examples illustrate a common problem in
prescribed medications. The instructions from the bottle
shown in Figure 5.21 are:
Take 5 tabs once daily x 3 days,
then 4 tabs once daily x 3 days,
then 3 tabs once daily x 3 days,
then 2 tabs daily x 3 days,
then 1 tab daily x 3 days.
Complying with these instructions requires the patient to
pay careful attention to detail and have a good memory or
to use some additional mechanism for tracking necessary
changes in dosages.
A typical prescription bottle may not adequately convey
detailed instructions. One approach to managing dosage
changes is to print the dosage for each day on a calendar.
This approach is cumbersome and increases the probability
of making an error in following the prescribed instructions.
The packaging, however, puts lots of knowledge in the
world (Figure 5.22) because the rows are labeled by day,
and the instructions for each day are printed on the line
below each row of pills. The act of taking a pill creates a
record of where the patient is in the sequence. No
calendar or other aid is needed.
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Example Set 5.8—Variations in "Take Your Medicine," Part II
For some, taking medications four times daily is not a
problem. For others, determining if they have taken their
medications is more problematic. Several approaches have
been created to help ensure that medications are taken as
prescribed. Clearly, some devices require less attentiveness,
and some approaches are more cost-effective than others.
The effectiveness of each approach depends on the
individual involved.
Figure 5.23 shows a daily pillbox. It is simple,
straightforward, and easy to use. This mistake-proofing
device is not particularly mysterious or clever. Yet, it is
common enough that it must work for someone. A
weakness of this device is that it provides only a visual cue
to take medications. It provides no mechanism to know
which pills to take at a particular time of day.
Birth control pills are sold packaged for use as a 1-month
supply. The packaging indicates whether or not patient
has been taking their medication consistently and are
current, assuming they know what day it is (Figure 5.24).
If clever packaging is not enough, the wristwatch in
Figure 5.25 can remind
the user to take medications up to six times a day. Instead
of an audible alarm, the watch vibrates discreetly.
The logical extension of the simple pillbox is shown in
Figure 5.26. This system has seven boxes. Each box
contains four compartments and a timer to remind the
patient to take the medicine in the next compartment.
If a timer is not enough, the medication dispenser in
Figure 5.27 dispenses the medications and detects when
they are removed. If the pills are not removed on a timely
basis, the dispenser places a phone call to a family member
or caregiver who can follow up with the appropriate party.
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Example Set 5.9—Variations in "Take Your Medicine," Part III
The next step in this progression towards more strict
control of medication dosing would be a device to ensure
that medications are actually administered. Even the most
sophisticated dispenser ensures only that the medication is
removed from the dispenser. The mistake-proofing devices
that follow take a different approach. Instead of
controlling the traditional process, new processes are
developed. The time-release capsule (Figure 5.28)
accomplishes the same goal as prescribing multiple doses
of a medicine but in a more mistake-proof way. The
patients need only to take a single pill.
The need to remember to take even a single pill has been
further reduced. Patches are used to administer
medications over much longer periods of time (Figure 5.29).
The design of the medication delivery method reduces the
need to remember to take medications.
Going one step further, the Norplant® system is embedded
in a woman's body for 5 years. This contraceptive is a set
of six small capsules that are placed under the skin of the
upper arm (Figure 5.30). They eliminate the need to
remember to take medication. One drawback is that the
implants must be removed after 5 years.
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Example Set 5.10—Examples from the Built Environment, Part I
New York-Presbyterian Hospital covers a city block with
interconnected buildings featuring addition after addition
(Figure 5.31). The interconnections inside these buildings
can cause navigational problems. Those familiar with the
layout of the hospital know that Building A connects to
Building B on the first and third floors, but not on the
second, or they may know that floor 15 of Pavilion X
connects to floor 16 of Y Building via the skybridge.
Patients who are newcomers to these buildings find it
difficult to navigate the hospital.
One way to improve a patient's ability to find their way
around is to mark well-traveled paths throughout the
facility. Paths could be marked using solid tape or painted
lines (Figure 5.32) or, like Hansel and Gretel's bread
crumbs, they could be marked with strategically placed
icons that lead to the desired destination. The colored
shoes (Figure 5.33) are from New York Presbyterian Hospital.
Magnetic fire doors (Figure 5.34) are widely used in many
types of commercial buildings. They are linked to fire
detection systems so that the doors are released, then close
when the fire detection system is activated. Closing the
door does not prevent fires. It temporarily prevents the
influence of mistakes, the fire, from spreading further.
During a fire or other emergency, many factors make it
easy for those descending to descend too far down the
stairwell and miss the street-level exit. The gate in Figure 5.35
provides a very strong cue that descending past that
point is discouraged. This gate, like the door in Figure 5.34, closes automatically when the fire alarm is tripped.
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Example Set 5.11—Examples From the Built Environment, Part II
St. Joseph's Hospital has designed every patient room so
that the sink is clearly visible (Figure 5.36). Patients are
encouraged to watch and ensure that staff members wash
their hands before interacting with them. In most rooms,
the doors open toward the sink (Figure 5.37), further
encouraging handwashing.
Each patient room is also provided with a nurse's alcove
that has all of the necessary supplies (Go to Chapter 7,
Example 7.27) and a computer for electronic
documentation of care accomplished before he or she
moves on to another patient. The door to the alcove has a
window so that the nurse can see the patient while
completing the chart (Figures 5.38 and 5.39).
The concept of being able to see the patient is taken to the
extreme in St. Joseph's intensive care unit (ICU). The
ICU is located along the curved back of the building. It is
engineered so that each patient's face can be seen from the
work area. Being able to see patients is considered so
important that the only exception to room standardization
in the entire hospital occurs here. The last two rooms
(most distant in Figure 5.40) had to be rotated 180
degrees so that the patients could be seen.
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Example Set 5.12—Examples from the Built Environment, Part III
At St. Joseph's Hospital, the bathroom is placed near the
head of the bed for fall prevention (Figure 5.41). In many
hospitals, however, the room plans for every other room
are rotated 180 degrees so that two rooms share a
common plumbing wall. Often, this requires the patient
to cross the middle of the room where no handrails are
available to support the patient and prevent falls. At St.
Joseph's hospital, the patient is provided with handrails
from the bedside to every part of the bathroom (Figures 5.42-5.45).
If human beings are prone to perform automatically, as if
on auto-pilot, perhaps making environments where that
auto-pilot will be correct is worthwhile. That is the
strategy for headwalls. Every room in the hospital has a
standardized arrangement; the Emergency Room (ER),
ICU, and medical/surgical rooms are all identical.
Subsequently, ER activities can spill over into adjacent
rooms in ICU during extremely busy times (Figures 5.46A
and 5.46B).
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Example Set 5.13—Getting X-Rays Right
The flasher plate (Figure 5.47) is a small window on the
x-ray film cassette that prevents film from becoming
exposed during the flashing of the patient's name onto the
film. The cassette is inserted into the name flasher, then
the flasher plate is automatically pulled back to expose the
film to a small light that exposes the patient's name on the
film (Figure 5.48). The flasher plate will only move when
it is inserted into the name-flashing device.
The film is marked as 'left' or 'right' for reference to
prevent the radiologist from misinterpreting the results
when reading the film (Figure 5.49).
In addition to marking the left and right sides, a
technologist's initials, film series, and other information
can be recorded with a blunt writing instrument.
Figure 5.50 shows a dental x-ray film holder that is
inserted in a patient's mouth. The hoop provides a target
for positioning the x-ray machine so that the dental
technician aligns it correctly each time.
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Example Set 5.14—Exposure Control
Figure 5.51 illustrates two mistake-proofing techniques to
prevent radiation exposure. The lighted sign over the x-ray
room door alerts personnel that an exposure is in progress.
When the x-ray machine is emitting x-rays, the exposure
light alerts personnel that they should not enter the room.
The door interlock prevents exposure if the x-ray room
door is left open. A small switch in the door frame will
not allow an exposure to occur if the door is left open.
In Figure 5.52, the mistake-proofing takes the form of
personal protective equipment. The apron protects the
technician from overexposure to radiation.
On older x-ray units that have a cord attached to the
exposure button, the relatively short cord length does not
allow the technologist to make an exposure while outside
the protection of the control booth (Figure 5.53).
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Example Set 5.15—Bed Alarms and Fall Reduction
A number of mistake-proofing devices have been
developed to protect patients at risk for falls when getting
out of bed. Bed alarms (Figures 5.54 and 5.55) are
designed to notify caregivers when a patient gets out of
bed, come in a variety of sizes and shapes, and perform a
variety of functions.
In some cases, the alarm is built into the bed. In other
cases, it is added-on as needed. In one model, a pad is
placed under the bottom sheet and detects the patient's
body weight. Go to http://www.abledata.com/abledata.cfm?pageid=113583&top=0&productid=84241&trail=0.
Some sensors can be placed under the mattress. The
alarms come with many different sound alert options,
including voice warnings that can be recorded by a loved
one. One version will monitor how long a patient has
been out of bed and telephone a caregiver if the bed
remains unoccupied for too long. Go to http://www.bedmonitors.com/bedmonitors_how_works.htm.
The alarm in Figure 5.56 tethers the patient to the bed.
The device is strapped to the patient. The cord is attached
to the bed. The alarm will sound if the patient moves in a
way that pulls the cord, detaching the tether from the device.
The bed alarm in Figure 5.55 is placed on the floor beside
the bed so that an alarm sounds when a patient's feet
touch the floor. Other approaches considered by
manufacturers include the use of lasers and other
sophisticated sensors to detect when a patient tries to get
up. Go to http://www.norto.com.au/Norto-Emfit-Safebed.htm.
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Example Set 5.16—Sharps
Protecting staff, patients, and visitors from the biohazard
of "sharps" (exposed needles) takes many forms. The
syringe in Figure 5.57 is equipped with a cover for the
needle. The cover is inserted into the square base so that it
stands vertically. The needle can be inserted into the cover
using one hand. The other hand can be kept safely out of
the way. When the cover is used as intended, a
misjudgment in the insertion process will not result in a
needle stick.
The syringe in Figure 5.58 has a hinged cover so that it
can be easily closed with one hand and with a motion that
provides minimal opportunity for a needle stick. The cover
clicks into place and cannot be removed.
The needle in Figure 5.59 is nearly self-blunting. It is
inserted normally, but when the needle is withdrawn, a
sleeve containing a steel tip cover is held against the
patient's skin. The tip of the needle catches the cover,
pulling it from the sleeve. Devices that require less effort
and involve a more natural motion will usually be more
effective.
The scalpel in Figure 5.60 has a spring-loaded, retractable
blade. Push a button near the back of the handle and the
blade retracts.
A workbook on sharps safety by the Centers for Disease
Control and Prevention (CDC)9 states: "A passive safety
feature is one that requires no action by the user."
...Few devices with passive safety features are
currently available. Many devices currently marketed
as self-blunting, self-resheathing, or self-retracting
imply that the safety feature is passive. However,
devices that use these strategies generally require that
the user engage the safety feature... Although devices
with passive safety features are intuitively more
desirable, this does not mean that a safety feature that
requires activation is poorly designed or not desirable.9
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Example Set 5.17—Controlling the Controls
The IV pump in Figure 5.61 features a small button on
the back of the machine that can be used to lock the
controls so that others who are unfamiliar with the
equipment cannot tamper with the settings on the control
panel on the front of the machine.
The switch on this IV pump has a clear plastic cover that
prevents inadvertent bumping of the switch. Donald
Norman10 recommends making it harder to do what
cannot be reversed. The cover makes the equipment in
Figure 5.62 more difficult to use, but apparently, the
errors prevented more than compensate for the
inconvenience.
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Example Set 5.18—Software
Although most mistake-proofing devices can be
photographed, software applications cannot. A number of
logical checks can be performed, however, after
information has been entered into an application via
computer. The examples in this set show how software
interfaces can be used to mistake-proof some aspects of
medical processes.
The keypad on the radiology equipment in Figure 5.63
requires patient information to be entered prior to any exam.
Programmed protocols are pre-programmed instructions
to the machine that control how the exam will be set up
(Figure 5.64). This enables the operator to select the exam
and be confident that all the correct settings are in place.
It also ensures that exams are performed in a consistent
manner, regardless of who is operating the machine.
The system shown in Figure 5.65 reviews patient histories
and gives an alert if the blood type differs from the type
previously entered or if the patient's blood contained an
antibody. The system will also give a warning if a blood
type different from the patient's is cross-matched for
transfusion. An alert is given if the patient needs special
blood products.
For stereotactic breast biopsies, this unit (Figure 5.66)
contains protective software that, by calculating the
needle's position, prevents the improper insertion of a
biopsy needle that could result in patient injury.
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Example Set 5.19—Refrigeration Feedback
Blood bank refrigerators are equipped with temperature
monitors that sound an alarm if and when the
temperature is out of the safety range (Figure 5.67). The
alarms also produce continuous chart recordings (Figure 5.68) and visual digital readings (Figure 5.69).
The read-out "Status OK" indicates that the refrigerators
in this blood bank are operating properly. When the
temperature or other operating parameters are not correct,
a message scrolls across the display, indicating which
refrigerator is out of specifications and which specification
is violated.
The alarm system in Figure 5.70 is functional but not as
sophisticated as the other examples in this set. It features an
audible alarm and lights to indicate which zone is down.
This system benefits tremendously from the posted
instructions, a simple job aid that puts knowledge in the
world. It will be very useful when the alarm goes off. The
instructions indicate which refrigerator corresponds to each
zone and provides information about how to silence the
alarm and troubleshoot the problem. Troubleshooting begins
with ensuring that the door is sealed.
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Example Set 5.20—Mistake-Proofing Patient Interactions
As Chase and Stewart11 indicated almost 15 years ago, the
actions of the "customer" need to be mistake-proofed. These
two examples show how software can reduce variation in
processes for which patients' cooperation and precise
responses are critical to successful outcomes. Both examples
show that mistake-proofing the actions of health care staff
can only partially lead to truly mistake-proofing processes.
The actions and behaviors of patients, family, and loved ones
must also be mistake-proofed.
It is very important that patients lie as motionless as possible
during a CT exam. Breathing instructions are prerecorded
and embedded in multimedia software. When the operator
begins the exam, the correct breathing instructions are
automatically played to the patient at the correct time
without further operator intervention, helping ensure
patient cooperation and optimal results (Figure 5.71).
The blood donation software application in Figure 5.72 is
optimized by eliciting donor information through a Web-based
survey. The system provides on-screen text with
added privacy via earphone audio and other options, color
pictures to emphasize important aspects of questions, and
touch screens to eliminate "keyboard phobia" and mouse
aversions. The system contains donor self-interview and
staff-review modules. It prevents the production of a
donor record until the survey has been completed and a
staff member has judged the information to be acceptable.
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Example Set 5.21—Wristbands
Wristbands (Figures 5.73-5.75) have been used
extensively in medicine to provide sensory alerts for many
different patient conditions. Wristbands provide a physical
space for patient information to reside; efforts are
underway to put as much information onto a wristband as
possible. Color coding is widely employed to indicate
allergies, fall risks, do not resuscitate (DNR) orders, etc.
Improved printer functionality enables the placement of
multiple symbols and photos on the wristband, along with
a patient's name and date of birth. The wristband is also
the locus for more sophisticated patient identification
technologies such as bar coding. There is a magnetic data
storage device (capable of storing medical records)
mounted on the wristband in Figure 5.75.
Some hospitals place yellow wristbands on DNR patients.
There is some concern that yellow LIVESTRONG™
bracelets that help support the Lance Armstrong
Foundation's efforts to fund cancer research may be
mistaken for a DNR wristband. While no one has ever
died because of confusion between the two, some hospitals
are reportedly taping over LIVESTRONG™ bracelets
with white adhesive tape to be safe.12
This chapter discussed related sets of mistake-proofing
devices. Chapter 6 is concerned with medical and nonmedical
applications of mistake-proofing.
References
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2. Hinckley CM. Make no mistake. New York: Productivity Press; 2001.
3. Nikkan Kogyo Shimbun/Factory Magazine, ed. Poka-Yoke: Improving product quality by preventing defects. Portland, OR: Productivity Press; 1988.
4. Confederation of Indian Industry. Poka-Yoke book on mistake-proofing. New Delhi: Confederation of Indian Industry; 2001.
5. Bynum D. Domestic hot water scald burn lawsuits—The who, what, when, why, where, how. In: Petri VJ, et al. Annual ASPE Meeting. Indianapolis, October 25-28, 1998. See also http://www.tap-water-burn.com/#4. Accessed January 2007.
6. Anderson TM. Harry S. Truman VA Hospital. Columbia, MO: Written communication; March 12, 2004.
7. Department of Health, The Design Council. Design for patient safety. London: Department of Health and Design Council; 2003.
8. Tsuda Y. Implications of foolproofing in the manufacturing process. In: Quality through engineering design. Kuo W, ed. New York: Elsevier; 1993.
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