Mistake proofing: changing designs to reduce error

Abstract

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.

Evaluation of Safety in a Radiation Oncology Setting Using Failure Mode and Effects Analysis

“…This is accomplished by either decreasing the occurrence frequency (ideally making it impossible for that particular error to occur), by increasing its detectability and thereby lowering the detectability score, or by decreasing its severity if it does occur ( e.g., stopping treatment after one fraction if diode readings indicate an error). Accepted and proven steps to mistake-proofing are as follows (14–19): (1) eliminate the task or part, thereof, (2) replace the task or part with a more reliable one, (3) engineer the task or part to make the error impossible, (4) make work easier to perform (5) make variations and deviations more obvious, and (6) minimize the effects of errors.…”

Safety by design: effects of operating room floor marking on the position of surgical devices to promote clean air flow compliance and minimise infection risks

“…Lowe29 showed the contribution of latent conditions to patient safety in the design of ORs and other hospital areas, finding that 27% of all medical devices were designed without adequately addressing human factor issues. Grout12 argues for ‘mistake proofing’ by changing designs to make processes more reliable and effective. Safety and quality approaches in hospital care, therefore, should include a human factors approach that focuses on system design in addition to teaching clinical and non-technical skills.…”

“…Most safety improvements in high-risk industries first focus on work area design—here defined as ‘creating and developing concepts and specifications that optimise the function value and appearance of products and systems for the mutual benefit of both user and manufacturer’12—before attempting to change behaviour. Many studies performed in industry have concluded that it is hard to change behaviour; changing design is probably easier, although there is a mutual relationship between both factors 13–17.…”

Safety Strategies in an Academic Radiation Oncology Department and Recommendations for Action

“…We also used Grout’s four approaches to reduce human error, including mistake prevention, mistake detection, process design to fail safely, and work environment design to prevent errors, as guidance. 29 …”