What is mistake-proofing?

Mistake-proofing, or poka-yoke in Japanese, means making sure that a specific task, or series of tasks, occurs without a hitch all the time. It fits well within the key Lean idea of avoiding waste.  Indeed, why spend precious time discussing errors and trying to correct them? Is there not a better way?

The paradigm shift of mistake-proofing

In mistake-proofing a process, speed is not necessarily a goal. What mistake-proofing does, however, is put a laser-like focus on making the occurrence of an error an impossibility. Needless to say, the potential to positively impact harm events is enormous — think erroneous blood transfusions, wrong-side surgeries, and premature inpatient discharges.

Mistake-proofing is not to be confused with fail-safe design, which concerns itself with ensuring that failures, when they occur, have no serious consequences — think, for example, of the Otis elevator brake and the anti-tipover design of filing cabinets, which allows for only one drawer to be open at a time.

Mistake-proofing and fail-safe design, when combined, are quite powerful.

Mistake-proofing requires radically rethinking our work environment and processes.  Mistake-proofing is based on a key idea often not understood or fully appreciated as being fundamental, a paradigm shift as to where knowledge resides. How so?  In mistake-proofing, one alleviates the cognitive burden on already overextended staff and builds intelligence into the operational environment or process. This approach differs radically from the typical over-reliance on costly training and re-training of staff, and eventually on what would have to be perfect recall of information by them to carry out a task properly. It also reduces the burden of supervision and auditing on managers.

Mistake-proofing also represents a conceptual shift as to when knowledge is applied to the analysis of a process or problem with respect to the typical Root Cause Analysis (RCA) mindset.  Why? While RCA attempts to diagnose the causes of a problem, by definition it does so only once an error has occurred.  In other words, the admission is implicit that one is willing to have an error occur.  Or perhaps one simply lacks the awareness that a better alternative exists.

Compared to RCA, a tool that is more closely aligned with  mistake-proofing is Failure Modes and Effects Analysis (FMEA). Indeed, FMEA emphasizes gauging and eliminating or mitigating risk ahead of time, as well as providing an increased focus on how and what to test, all of which support a philosophy of preventing errors rather than dissecting them after the fact.

Healthcare organizations need to ask themselves if they want to live with errors that they hope to correct, or if they want to make the not insignificant effort to ban errors from occurring in the workplace and benefit not also from reduced harm but from less rework and waste related to error analysis and correction.

 

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