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Lean Education

Lean Education. Error Proofing. The tool. What is it? What’s it for? How does it work? When do you use it? What’s an example?. What is it?. Error Proofing is a method of identifying ways to eliminate or reduce errors in a process There are multiple levels of solutions

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Lean Education

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  1. Lean Education Error Proofing

  2. The tool • What is it? • What’s it for? • How does it work? • When do you use it? • What’s an example?

  3. What is it? • Error Proofing is a method of identifying ways to eliminate or reduce errors in a process • There are multiple levels of solutions • Level 1 – total elimination • Level 2 – reduction of error rate (when elimination not possible)

  4. Error Proofing – Is it Needed? “Between 44,000 and 98,000 people die each year nationwide as a result of avoidable errors in hospitals… Safety does not reside in a person, device or department, but emerges from the interactions of components of a system.” Errors can include problems in practice, products, procedures and systems. The usual responses to such errors focus on preventing recurrence by punishing or retraining individuals. These responses tend to be ineffective because they ignore the system and instead focus on one particular set of circumstances that are unlikely to reoccur. To Err is Human: Building a Safer Health System, Institute of Medicine (IOM) Read for Free at: http://www.nap.edu/books/0309068371/html/

  5. Error Proofing – Is it Needed? Kidney Transplant wrong side Unnecessary radical jaw surgery Surgical sponge and gauze left in breast Surgical tool left in stomach The New York Times Magazine, March 16, 2003

  6. Error Proofing – Is it Needed? OLD CNN, November 21, 2007 NEW

  7. How does it work? • Weaknesses in processes are identified by observation, measurement, or other methods • Ideas for eliminating errors are collected, evaluated, and tested • The most effective and practical solution(s) are implemented

  8. When do you use it? • When errors are identified and are causing a process to be inefficient • When harm is coming to patients, regardless of frequency or difficulty of correction

  9. Error Proofing • Process for avoiding simple human errors: • Makes Zero Defects possible • Eliminates need for additional inspections • Shows respect for intelligent workers • Frees a worker’s time and mind to pursue creative, value-adding activities • Attitude: It is NOT acceptable to produce even a small number of defects

  10. Level 1: Total PreventionDefect cannot be made Outlets for various types of gases are “keyed” in such a way that wrong connections can not be made. All connectors have a pin at the 12 o’clock position, but differ on the second position. Level 1: Keying Level 2: Color Coding “Condition H” (Shadyside, Patient/Family call for RRT Credit to John Grout, Berry College, www.mistakeproofing.com/medical

  11. Level 1: Total PreventionDefect cannot be made • Error: esophageal intubation (putting a tube into a patient’s stomach which was intended for their lungs) • Error proof: Squeeze bulb and put on tube. If bulb inflates, the tube is in the lungs. If not, tube is incorrectly placed in the esophagus. Credit to John Grout, www.mistakeproofing.com/medindex.html

  12. Level 2: Hand Washing Before Entry “Stop”/Go Arm is Up Light Sensor under Sanitizers – both inside room and out – raises the “Stop” arm Kevin Frieswick at MetroWest Medical Center http://www.leanblog.org/2009/04/leanblog-podcast-65-error-proofing/

  13. More Error Proofing Examples NG tube cannot be connected to an IV port Yellow tubing is attached to all epidural meds and serves as a visual indicator http://mmpp.wikispaces.com/

  14. Error Proofing in Practice Lab: Barcode scanner was implemented to scan and identify specimens quickly and without errors. ER: Pyxis-for all critical supplies; not just for drugs

  15. Error Proofing in Practice • Sanjay Saint, MD, Univ. of Michigan Healthcare System implemented a reminder system for physicians to remove the urinary catheters of hospitalized patients. • Indwelling urinary catheters are placed in ~25% of hospital patients. • Estimated 40% of infections developed during hospital stay are urinary tracts infections, most due to urinary catheters. • The reminder system error proofs the process by helping the doctor know which patients have catheters, how long they have been in, and when to order removal. Study results showed that each patient’s hospital stay that involved a catheter went down by 7.6% on the “reminder” wards. And, the written-reminder system isn’t expensive. • Dr. Sanjay SaintUMHS in BCBSM’s Highlights Newsletter Read for Free at: http://www.bcbsm.com/foundation/pdf/05highlights.pdf

  16. Questions?

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