Poka‐yoke (mistake‐proofing) is a powerful quality improvement approach, which usually employs relatively simple devices to achieve marked improvements. Inexpensive jigs, fixtures, switches, and gauges act as obvious environmental cues to signal mistake detection. Poka‐yoke has been largely ignored as an avenue for serious academic research. This paper provides scientific underpinning to the largely anecdotal mistake‐proofing literature, by drawing upon research from psychology and cognitive science concerning human error. We delineate areas where additional research would be worthwhile, and guide practitioners in understanding what they are trying to accomplish and how poka‐yoke devices attain this end.

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Mistake proofing uses changes in the physical design of processes to reduce human error. It can be used to change designs in ways that prevent errors from occurring, to detect errors after they occur but before harm occurs, to allow processes to fail safely, or to alter the work environment to reduce the chance of errors. Effective mistake proofing design changes should initially be effective in reducing harm, be inexpensive, and easily implemented. Over time these design changes should make life easier and speed up the process. Ideally, the design changes should increase patients’ and visitors’ understanding of the process. These designs should themselves be mistake proofed and follow the good design practices of other disciplines.

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