1st Edition

Mistake Proofing for Lean Healthcare

Edited By Samuel Carlson, MD, Maura May Copyright 2016
    111 Pages 146 B/W Illustrations
    by Productivity Press

    111 Pages
    by Productivity Press

    The principles of mistake proofing, long used to eliminate errors and defects across a range of industries, are now being applied in healthcare organizations around the world to help ensure patient safety, improve services, and eliminate waste.

    Mistake Proofing for Lean Healthcare
    is based on the definitive mistake-proofing philosophy and system developed by Shigeo Shingo. This reader-friendly book introduces the main concepts and benefits of mistake proofing in healthcare and highlights common reasons that errors and defects occur. It also explains how to catch errors before they become defects, using the concept of "source inspection," so you can ensure quality before a process is performed instead of afterward. When systematically used, the mistake-proofing approach explained in this book will help you:

    • Create safer, more reliable, and more effective healthcare services for both patients and staff
    • Establish a culture in which mistakes and the conditions that cause them are readily surfaced so they can be corrected
    • Lay the foundation for processes that flow smoothly, without disruption
    • Eliminate rework, waste, and the need for extra resources and supplies

    Presenting real-world healthcare examples, the book shows different types of mistake-proofing devices and methods (poka-yoke) that provide feedback quickly and automatically to prevent errors and defects.

    The book is part of the Lean Healthcare Series and is designed for individual or group learning. Each chapter includes reflection questions to facilitate understanding and stimulate discussion and action.

    Getting Started
    Purpose of This Book
    What This Book Is Based On
    Two Ways to Use This Book
    How to Get the Most Out of Your Reading
         Become Familiar with This Book as a Whole
         Become Familiar with Each Chapter
         Using a Reading Strategy
         Using the Margin Assists
    Overview of the Contents
         Chapter 1: Getting Started
         Chapter 2: The Production Processes and Operations of Healthcare
         Chapter 3: Introduction to Mistake Proofing
         Chapter 4: Basic Elements of the Mistake-Proofing System
         Chapter 5: Using Poka-Yoke Systems
         Chapter 6: Examples of Poka-Yoke Applications
         Chapter 7: Reflections and Conclusions

    The Production Processes and Operations of Healthcare
    The Industrial Origins of Lean Healthcare
    Production, Process, and Operation
    Principles of Lean Healthcare Management
         Standard Work
         Autonomation
         Flow Production
         Plan–Do–Check–Act
         Socratic Method
    Summary
    Reflections

    Introduction to Mistake Proofing
    What Is Mistake Proofing?
    Why Focus on Zero Defects?
    How Mistake Proofing Makes Work Easier
    What Causes Defects?
         Communication Errors
         Cognitive Errors
         Red-Flag Conditions
    Controlling Conditions So Defects Do Not Happen
         The Traditional Quality Improvement Cycle
         Integrating PDCA in the Mistake-Proofing Approach
    Summary
    Reflections

    Basic Elements of the Mistake-Proofing System
    Quality at the Source
    The Four Elements of Mistake Proofing
    Three Approaches to Inspection
    Judgment Inspections Reveal Defects
    Informative Inspections Reduce Defects
         Statistical Quality Control
         Successive Checks
         Self-Checks
    Source Inspection Keeps Errors from Becoming Defects
    100 Percent Inspection Catches All Errors
    A Short Feedback Loop Means Quicker Action on Problems
    Poka-Yoke Systems Catch Errors We Might Have Missed
    Summary
    Reflections

    Using Poka-Yoke Systems
    About Poka-Yoke Systems
    Poka-Yoke Systems in Source Inspection and in Informative Inspection (Self-Checks and Successive Checks)
    How Poka-Yoke Systems Regulate the Process
    Types of Poka-Yoke Systems
    Method Poka-Yokes
         Checklists in Healthcare
         Using Checklists Effectively
         Stop the Line—Stop the Process
    Physical Poka-Yokes
         Contact or Identification Techniques
         Fixed-Value or Number Techniques
         Motion-Step or Sequence Techniques
    Poka-Yoke Sensors
    Devices that Link to Poka-Yoke Sensors
    Summary
    Reflections

    Examples of Poka-Yoke Applications
    Learning from Examples of Poka-Yoke Applications
    Method Poka-Yoke Examples
         Thoracic Surgery Checklist
         Red Event Safety Alert, Incident Command Checklist
         Chart Preparation Checklist
         Rounding Checklist
         Clinician Previsit Checklist
         Electronic Health Systems
    Contact or Identification Poka-Yoke Examples
         Integrated Color-Coding Systems
         Other Color-Coding Poka-Yokes
         Wristbands with Bar Codes or Radio-Frequency Identification Tags
         Tactile Signals on Wrong Buttons
         Throat Pack Identification
         Shrink-Wrapping on Dangerous Medications
    Fixed-Value or Number Poka-Yoke Examples
         Surgical Sponge-Counting Systems
         Automatically Timed Processes
         Automated External Defibrillator
         Bed Angle Visual Aid
         Pulse Oximeter
    Motion-Step or Sequence Poka-Yoke Examples
         Oral Care Pegboard
         Glucose Test Reminder
         Hand Hygiene Monitoring Systems
         Sheathed Needles
    Summary
    Reflections

    Reflections and Conclusions
    Reflecting on What You Have Learned
    Applying What You Have Learned
         Possibilities for Applying What You Have Learned
         Your Personal Action Plan
         Opportunities for Further Learning
    Conclusion
    Index

    Biography

    MD Carlson