1. Reducing Medical Error by Learning from Existing Examples of Mistake-Proofing John R. Grout Campbell School of Business Berry College, Mt. Berry, GA jgrout@berry.edu 706-238-7877

2. Mistake-proofing in healthcare Human factors proponents: –“forcing functions should be implemented in health care.” –“The remedy is in changing systems of work. The remedy is in design.” (Berwick) Actual examples tend to be scarce.

3. Mistake-proofing in healthcare Collection of 148 examples Examples of diverse approaches to mistake-proof common medical events Examples of similar approaches to mistake- proofing medical and non-medical domains. How examples fit frameworks proposed: –Chase and Stewart, –Shingo, –Tsuda, –Nakajo.

4. Methodological Challenges/Caveats Convenience sample Some contributors can “see” more devices than others Filtered by my understanding of medical processes Filtered by what I think are more “interesting” devices Filtered by what I think is a mistake-proofing device.

5. 19 th century example of mistake-proofing in healthcare

6. Portable Esophageal Intubation Detection Diverse approaches to common medical events

7. Take your medicine Diverse approaches to common medical events

8. Stay in bed Diverse approaches to common medical events

9. “Self-Blunting” Sharps Diverse approaches to common medical events

10. Connections Galore Diverse approaches to common medical events

11. Patient Interactions CT exam breathing instructions Blood donor interviewing Diverse approaches to common medical events

12. Similar approaches in medical and non-medical domains. Is medicine really all that different? Unit of blood transfused in Mary Smith vs. Maria Smith Package delivered to Wood Valley Ct. vs. Wood Valley Dr. …Only in terms of severity

13. See the difference? Medical solution Non-medical solution

14. See the difference? Medical solution Non-medical solution

15. See the difference? Medical solution Non-medical solution

16. See the difference? Medical solution Non-medical solution

17. See the difference? Medical solution Non-medical solution

18. See the difference? Medical solution Non-medical solution

19. See the difference? Medical solution Non-medical solution

20. Chase and Stewart Framework Customer Mistake-Proofing 41 of the 148 devices (27.7%) Provider Mistake-Proofing 107 of the 148 devices (72.3%)

21. Shingo Framework Setting function Regulatory function With enhancements by Chase & Stewart and Beauregard, Mikulak, & McDermott

22. Tsuda’s Framework

23. Nakajo’s Data Nakajo’s Framework

24. Make or buy

25. What’s ahead? Hard work … Few locally developed devices Preliminary observations seem to indicate that healthcare FMEA’s are not leading to design changes, mistake- proofing, or human factors improvements.

26. Thank you! Questions?