Error Proofing

According to a 2005 World Health Organization Report on Patient Safety, they revealed that 4% of patients suffer some kind of harm in hospital; 70% of the adverse events result in short-lived disability, and 14% of the incidents lead to death. A report from The Institute of Medicine (IOM) estimated that "medical errors" cause between 44,000 and 98,000 deaths annually in hospitals in the USA. The UK Department of Health, in its 2000 report, estimated that adverse events occur in approx. 10% of hospital admissions or about 850,000 adverse events a year.

Adverse events exact a high toll in financial loss as well. In the UK consequent additional hospital stays alone cost about £2000 million a year, and paid litigation claims cost the National Health Service around £400 million annually, in addition to an estimated potential liability of £2400 million for existing and expected claims. The total national cost of preventable adverse medical events in the USA, including lost income, disability and medical expenses, is estimated at between US$17,000 million and US$29,000 million annually. Added to these costs is the erosion of trust, confidence and satisfaction among the public and health-care providers.

Since errors in healthcare can be the difference between life and death, the more we can do to prevent them the better. Errors also impact financial costs and increase the stress levels of staff. With these major concerns, it is critical to design and continually strive for an error-proof process. In an industry where human life is at stake 99% quality should never be good enough. In some other environments where the well being of humans is not at stake, 99% would be OK. Could you imagine if only 99% of the worlds bridges were stable, if our cars only started 99/100 times or our telephones only connected 99% of our calls? The result would be collapsed bridges, stranded motorists and many missed conversations.

Error Proofing

The ultimate goal in error-proofing is to design a system that will detect and prevent errors from happening. Visual inspection is a possible method of removing errors but it is only 80-90% effective. For instance, how many people go straight through intersections without ever seeing the stop sign? There are many examples of error-proofing in our everyday life. Some examples are the overflow drain on sinks, auto shut off on small appliances and alarms for seat belts on cars. An example of a preventative "Poka Yoke" is that your car will not allow you to remove the keys unless the gear shift is in the park position. This prevents the car from being able to move while unattended.

While redesigning and standardizing our processes it is very important that we are mindful of any step where an error can happen and we design the best possible Poka Yoke to prevent it from being able to happen. Inspection isn't reliable enough to risk human life. We must integrate strategies to prevent and detect errors before the process is complete.

Every process has variation and most processes are very complex. Our challenge is to remove the variation so that all processes are predictable and consistent. The ultimate goal, as stated above, is to design the processes to ensure errors won't happen. In most cases, to eliminate or prevent errors, we must develop processes where humans and equipment, because of the error-proofing mechanisms put in the system, are not able to make mistakes and variation is restricted.

Effective error-proofing is able to detect and prevent errors reliably and consistently without being affected by emotion or distractions. It does not normally replace the need for human intervention, but it does assist in bringing the concern/problem to the attention of the staff before the problem can interfere with the next step in the process.