Effective Mistake-proofing for Healthcare:Principles & Techniques for Sustained ImprovementPresented by:Brian Nass BSEE, M...
Patient storyCopyright ©2013 Lean Advisors Inc.
Patient storyCopyright ©2013 Lean Advisors Inc.
Patient storyCopyright ©2013 Lean Advisors Inc.
• Highly-trained, highly-skilled caregivers• Needs of the patient at the forefront• Safety mechanisms in place• Required r...
Read this sentenceFINISHED FILES ARE THE RE-SULT OF YEARS OF SCIENTIF-IC STUDY COMBINED WITHTHE EXPERIENCE OF YEARS.How ma...
Read this sentenceFINISHED FILES ARE THE RE-SULT OF YEARS OF SCIENTIF-IC STUDY COMBINED WITHTHE EXPERIENCE OF YEARS.The an...
ObjectivesUnderstand what is meant by defect-freephilosophyUnderstand why errors occurUnderstand what is meant by mistake-...
DefinitionsMistake› An error in intent, leading to awrong actionSlip› An error in execution of anaction, even though the i...
DefinitionsProcess Defect› An undesirable outcome› Any instance of not meeting patient,customer, institutional, or regulat...
Examples of defects› Turn-around time beyond customer’sexpectation› Wrong-site surgery› Patient leaving ED without being s...
Defect-free philosophy• While humans are error-prone, our processesneed not create defects• Error- and defect-free process...
Mistake-Proofing SolutionsPrevention-based› Senses an abnormality that is aboutto happen and keeps it fromhappening OR› Ke...
Mistake-Proofing SolutionsDetection-based› Senses an abnormality once ithas occurred, highlights theoccurrence, so that co...
Mistake-ProofingWell-designed mistake-proofing solutions(“devices”)…..› Are devised by the people closest to thework› Prev...
Examples from our daily lives12345Copyright ©2013 Lean Advisors Inc.
Mistake-proofing in common use in healthcare17
Defects- “Triggers”Latent Failures- “Resident Pathogens”Observed defectsare a small part ofthe larger picture ofhuman erro...
The PathFigure out what’shappening andwhyRemove as manydrivers of error thatyou canDesign each task withina process so tha...
It’s NOT About Assigning Blame…It is natural for people to make mistakesIt is natural for people to miss a defectIt is nat...
Berwick on Humans and Error“...We are human and humans err. Despiteoutrage, despite grief, despite experience, despite our...
Where Does Human Error Commonly Come From?Deficits of› Attention› Working memory› Decision makingOur strong pattern recogn...
THE PAOMNNEHAL PWEOR OF THEHMUAN MNID“I cdnuolt blveiee that I cluod aulaclty uesdnatnrd what Iwas rdgnieg.Aoccdrnig to a ...
Human FactorsThe study of human capabilities andlimitations› How we think› How we act/ What we do› What we use to do itCop...
Human Factors TriangleCOGNITIONTASKTOOLSHow do we make decisions?How do we learn?How does our attention work?How do we mul...
When should I go??Copyright ©2013 Lean Advisors Inc.
Copyright ©2013 Lean Advisors Inc.
Mistake-Proofing Priorities1. Eliminate - remove step from process2. Prevent - eliminate root causes of error3. Detect - d...
How to proceedWhere are defectsproduced and what errorslead to each?At what process stepdoes each errororiginate?What is t...
Assessing Efficacy of the “Device”• Is it automatically triggered?• Does it prevent wrong actions?• If not preventive, doe...
Mistake proofing example:Reducing CLABSI (dramatically)Copyright ©2013 Lean Advisors Inc.
1. Slap on the wrist (or warning thereof)2. Re-training3. Double checks4. Replace the person(s) with others with moreexper...
Separate handouts provided:1. “Red Flag” conditions2. Reading list3. Double checks: design guidelinesThank you!Copyright ©...
Frequently Asked QuestionsContact US:877-778-6413corp@leanadvisors.comwww.leanadvisors.comCopyright ©2013 Lean Advisors Inc.
Mistake proofing presentation
Mistake proofing presentation
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Mistake proofing presentation

  1. 1. Effective Mistake-proofing for Healthcare:Principles & Techniques for Sustained ImprovementPresented by:Brian Nass BSEE, MSME, MSIESenior Advisor, Lean Advisors Incwww.leanadvisors.com1
  2. 2. Patient storyCopyright ©2013 Lean Advisors Inc.
  3. 3. Patient storyCopyright ©2013 Lean Advisors Inc.
  4. 4. Patient storyCopyright ©2013 Lean Advisors Inc.
  5. 5. • Highly-trained, highly-skilled caregivers• Needs of the patient at the forefront• Safety mechanisms in place• Required resources on handWhat do these situations have in common?Then why were there bad outcomesfor these patients, their families, and thecaregivers?Copyright ©2013 Lean Advisors Inc.
  6. 6. Read this sentenceFINISHED FILES ARE THE RE-SULT OF YEARS OF SCIENTIF-IC STUDY COMBINED WITHTHE EXPERIENCE OF YEARS.How many Fs are there in the above sentence?(Count them one time only)The answer is……Copyright ©2013 Lean Advisors Inc.
  7. 7. Read this sentenceFINISHED FILES ARE THE RE-SULT OF YEARS OF SCIENTIF-IC STUDY COMBINED WITHTHE EXPERIENCE OF YEARS.The answer is……6How many Fs are there in the above sentence?(Count them one time only)Copyright ©2013 Lean Advisors Inc.
  8. 8. ObjectivesUnderstand what is meant by defect-freephilosophyUnderstand why errors occurUnderstand what is meant by mistake-proofing and identify best mistake-proofingstrategiesUnderstand how consideration of humanfactors can help in developing solutions forimprovementKnow what to do next and how to do itCopyright ©2013 Lean Advisors Inc.
  9. 9. DefinitionsMistake› An error in intent, leading to awrong actionSlip› An error in execution of anaction, even though the intent wascorrectCopyright ©2013 Lean Advisors Inc.
  10. 10. DefinitionsProcess Defect› An undesirable outcome› Any instance of not meeting patient,customer, institutional, or regulatoryrequirements› An un-necessary outcomeDefects are also acategory of WASTE.Copyright ©2013 Lean Advisors Inc.
  11. 11. Examples of defects› Turn-around time beyond customer’sexpectation› Wrong-site surgery› Patient leaving ED without being seen› Prescription filled incorrectly› Patient dissatisfied with the food› Lost specimen› Any instance where we paid expeditecharges to mail something out(e.g., used Fed Ex) when it wasn’tnecessaryDefinitions
  12. 12. Defect-free philosophy• While humans are error-prone, our processesneed not create defects• Error- and defect-free processes are achievedthrough improved process designCopyright ©2013 Lean Advisors Inc.
  13. 13. Mistake-Proofing SolutionsPrevention-based› Senses an abnormality that is aboutto happen and keeps it fromhappening OR› Keeps the process from movingforward until all required elementsare present and correct13
  14. 14. Mistake-Proofing SolutionsDetection-based› Senses an abnormality once ithas occurred, highlights theoccurrence, so that correctiveaction can take place at the pointof origin14
  15. 15. Mistake-ProofingWell-designed mistake-proofing solutions(“devices”)…..› Are devised by the people closest to thework› Prevent error› Provide immediate feedback› Compel countermeasure(s)› Make it impossible to do the wrong thing› Are simple and inexpensiveCopyright ©2013 Lean Advisors Inc.
  16. 16. Examples from our daily lives12345Copyright ©2013 Lean Advisors Inc.
  17. 17. Mistake-proofing in common use in healthcare17
  18. 18. Defects- “Triggers”Latent Failures- “Resident Pathogens”Observed defectsare a small part ofthe larger picture ofhuman error18
  19. 19. The PathFigure out what’shappening andwhyRemove as manydrivers of error thatyou canDesign each task withina process so that it ishard to do the wrongthing and easy to do theright thingMake your processmore robust againsterrors (mistake-proofed)Copyright ©2013 Lean Advisors Inc.
  20. 20. It’s NOT About Assigning Blame…It is natural for people to make mistakesIt is natural for people to miss a defectIt is natural for people to not notice…› an IV pump malfunctioning› dosing calculation not quite right› vital signs that are incorrect› equipment alarmingCopyright ©2013 Lean Advisors Inc.
  21. 21. Berwick on Humans and Error“...We are human and humans err. Despiteoutrage, despite grief, despite experience, despite ourbest efforts, despite our deepest wishes, we are bornfallible and will remain so. Being careful helps, but itbrings us nowhere near perfection... The remedy is inchanging systems of work. The remedy is in design. Thegoal should be extreme safety. I believe we should be assafe in our hospitals as we are in our homes. But wecannot reach that goal throughexhortation, censure, outrage, and shame. We can reachit only by commitment to change, so that normal, humanerrors can be made irrelevant to outcome, continuallyfound, and skillfully mitigated.”Berwick DM. Not again! BMJ 2001;22:247-8.Copyright ©2013 Lean Advisors Inc.
  22. 22. Where Does Human Error Commonly Come From?Deficits of› Attention› Working memory› Decision makingOur strong pattern recognitionSimilarity between different tasks“Automaticity” in task performanceWeakened mental or physiological stateCopyright ©2013 Lean Advisors Inc.
  23. 23. THE PAOMNNEHAL PWEOR OF THEHMUAN MNID“I cdnuolt blveiee that I cluod aulaclty uesdnatnrd what Iwas rdgnieg.Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, itdeosnt mttaer in what oredr the ltteers in a wrodare, the olny iprmoatnt tihng is that the first and lastltteer be in the rghit pclae. The rset can be a taotl msesand you can sitll raed it wouthit a porbelm. This isbcuseae the huamn mnid deos not raed ervey lteter byistlef, but the wrod as a wlohe.Amzanig, huh?”What are the implications of this?Copyright ©2013 Lean Advisors Inc.
  24. 24. Human FactorsThe study of human capabilities andlimitations› How we think› How we act/ What we do› What we use to do itCopyright ©2013 Lean Advisors Inc.
  25. 25. Human Factors TriangleCOGNITIONTASKTOOLSHow do we make decisions?How do we learn?How does our attention work?How do we multi-task?What is the nature of the task?How do we know what to do next?What influences our ability to do it?Do we understand what successfultask execution looks like?What tools are we given?How easy or difficult are they to use?What is their efficacy?How do we know if theyare used correctly?Copyright ©2013 Lean Advisors Inc.
  26. 26. When should I go??Copyright ©2013 Lean Advisors Inc.
  27. 27. Copyright ©2013 Lean Advisors Inc.
  28. 28. Mistake-Proofing Priorities1. Eliminate - remove step from process2. Prevent - eliminate root causes of error3. Detect - detect when erroroccurs, enabling immediate correctionat the point of occurrence4. Manage – contain defects within theprocess before they reach thecustomer/patientBEST!Copyright ©2013 Lean Advisors Inc.
  29. 29. How to proceedWhere are defectsproduced and what errorslead to each?At what process stepdoes each errororiginate?What is the natureof the errors (orcombinations)?Perform root causeanalysis to uncovercombinations of factorsleading to errorDesign your mistake-proofing “device”Estimate its strengthTry it outMeasure the resultsDetermine howyour “device” couldbe made strongerCopyright ©2013 Lean Advisors Inc.
  30. 30. Assessing Efficacy of the “Device”• Is it automatically triggered?• Does it prevent wrong actions?• If not preventive, does it shut down the process?• If not a shut down, does it effectively alarm theperson making the error?• To what extent can people create work-arounds?• To what extent can we sustain this “device”?• How feasible is this to implement?Copyright ©2013 Lean Advisors Inc.
  31. 31. Mistake proofing example:Reducing CLABSI (dramatically)Copyright ©2013 Lean Advisors Inc.
  32. 32. 1. Slap on the wrist (or warning thereof)2. Re-training3. Double checks4. Replace the person(s) with others with moreexperience/skill5. Add technology to the process step/activity6. Add more staffCaution: watch out for thesecommon “interventions”What is the efficacy of the above?What issues do you see with the above?Copyright ©2013 Lean Advisors Inc.
  33. 33. Separate handouts provided:1. “Red Flag” conditions2. Reading list3. Double checks: design guidelinesThank you!Copyright ©2013 Lean Advisors Inc.
  34. 34. Frequently Asked QuestionsContact US:877-778-6413corp@leanadvisors.comwww.leanadvisors.comCopyright ©2013 Lean Advisors Inc.

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