Six Principles of Mistake Proofing Care


In the arena of mistake proofing, replacement means replacing one operation with a more reliable machine/method/automation.

In complex systems many operations within a process develop over time with little thought to the actual implementation of the process. Operations which have dependencies should be tied together so one step cannot be completed without the inclusion of the prior step. This is known as a “forcing function”.

Click on the images below for examples.


A word of caution:
Though it may seem efficacious to replace an entire system, this can lead to more confusion and may have other unforeseen consequences. This is a scenario of “throwing out the baby with the bath water”. All systems have potential issues. It is often necessary to drill further into a system to understand the potential issues before making any decision to move to a new process or system. Often the “fix” is easier than it seems, and will be less work than implementing an entirely new process or system. Proper analysis and determination of the operations in the current system will pay off greater dividends than just starting over.

Thought Question:
Would you consider hospital implementation of Computerized Physician Order Entry (CPOE) as an effective example of Replacement?


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