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
 Level 1 – total elimination
 Level 2 – reduction of error rate (when
elimination not possible)
 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/

Error Proofing – Is it Needed?

Kidney
Unnecessary
Transplant
radical jaw
wrong side
surgery

Surgical Surgical
sponge and tool left in
gauze left in stomach
breast

The New York Times Magazine, March 16, 2003

Error Proofing – Is it Needed?

OLD

CNN, November 21, 2007

NEW
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
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
 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
 Level 1: Total Prevention
Defect 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
 Level 1: Total Prevention
Defect 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

 Level 2: Hand Washing Before Entry
Light Sensor under “Stop”/Go Arm is Up
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/
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/
Error Proofing in Practice

ER: Pyxis-for all critical Lab: Barcode scanner was

supplies; not just for implemented to scan and identify
drugs specimens quickly and without
errors.
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 Saint UMHS in BCBSM’s Highlights Newsletter

Read for Free at: http://www.bcbsm.com/foundation/pdf/05highlights.pdf

Questions?