A simple example of mistake-proofing

Consider a simple example from an everyday domain that many of us may be familiar with.  Say there are two ways to connect a kitchen appliance’s AC power cord and plug to a wall socket, but only one is correct.  What to do?

Working towards mistake-proofing

Taking conventional thinking to an extreme for the sake of argument could lead one to labeling the cord/plug, labeling the socket, posting instructions on the wall next to the socket, training people repeatedly as to how the plug must go into the socket, and even having two people doing the task together — similar to IDV (Independent Double Verification), done in dispensing meds, which is costly.  In all of these instances, there is still no guarantee that a mistake will not be made, and one must trust that whoever is doing the task gets it right every time.  This requires relying on training and recall, on staff being attentive and scrupulous, on management keeping a careful watch, and on there being few or no distractions.  Errors occur, though, and root-cause analysis (RCA) often shows that the training may not have been optimal, that recall may be less than perfect, and that relying on the personal virtues of those involved may not be the soundest means of ensuring flawless performance.

That said, what else could one do?  The answer is well-known, and involves a polarized plug and socket, with plug prongs and socket holes matched by number, size, position, and/or orientation, so the plug can only go in one way.  The foremost safety reason behind this design is that there are a live and a neutral conductor at the wall power point, and these need to be matched to the live and neutral poles of the appliance. To those wondering why, it is because a switch needs to be placed in the live wire and not the neutral — the live wire takes current to the appliance, while the neutral returns it to the power point.  Having the switch in the neutral could leave the device energized internally while one thinks it is not, potentially leading to electrical shock and death.

The key point is that, in this instance, mistake-proofing the design has eliminated the possibility of a wrong connection, and of its inherent risk. No less important, it has also done away with the need for training and monitoring, and their related costs.

There are many examples of mistake-proofing in healthcare, meant to prevent harm to the patient: automatic wheelchair brakes, barcoding of meds, drug interaction checkers, anti-reflux valves, medical gas connections, and so on. More needs to be done in terms of adoption of the mistake-proofing mindset, however, and a broader awareness of the importance of mistake-proofing processes, devices, and our work environment is neeeded if we are to both prevent the occurrence of harm events and minimize the waste associated with error tracking and correction in their avoidable aftermath.

 

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