1st Edition
Mistake Proofing for Lean Healthcare
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