Mistake-proofing: improving the design of tools

and tasks

John Grout

Here are some photos of mistake-proofing solutions

Mistake-proofing is the use of process design features* to facilitate correct actions, prevent simple errors, or mitigate the negative impact of errors.

*these process design features can be referred to as “devices” or “counter-measures”

A discussion of the interaction of tools, tasks and people

– SEIPS interventions where tools interact with task and person

A discussion of the interaction of tools, tasks and people

• Principal findings – Simplification (process mapping, visual

systems (a.k.a. 5S))– Designing benign failures to avoid errors– Facilitating correct action

Interaction of tools, tasks and people: Visual Systems

Simple design changes that make compliance with IHI’s VAP Best practice bundle easy to check visually.

Interaction of tools, tasks and people: Designing Benign Failures

Medical and non-medical examples see the difference?

Interaction of tools, tasks and people: Facilitating correct action

A discussion of the interaction of tools, tasks and people

• Challenges and remaining questions – Assessing FMEA recommended actions.

How design-oriented is it?– Leveraging existing examples to reduce the

creativity needed in design.

Translating What into How

Error typologySolution typology

Error

Solution

Abstract

Concrete

Examples

Hinckley’s 18 error categories

Hinckley’s 167 solution methods

Your errors

YourSolutions

150 Examples from book

Misread, mismeasure, misinterpret information

Main Category: information errors Detailed category:misread, mismeasure, misinterpret

15 make labels easy-to-read 7.6, 7.7, 7.28

18 eliminate transcriptions 8.18

22 distinguish related items by color (color coding) 7.7

25makes subtle distinctions obvious with organization and information 7.7

26 38

use graphics to simplify or clarify complexity and make interpretation easy 7.18

28look-alike items must have distinctive labeling 5.13B, 6.14, 7.5,

7.6, 5.21 (live strong)

30 provide information in units needed (avoid conversions) 7.1

32 make location of supplies accuated and obvious 8.18

34 check for compliance to specification limits 7.17, 8.14

40 print a required dimension guide on the worksheet 7.17

85 processes are designed to be standard operations 8.9

109 automate the execution 8.15, 8.18

135 print information once 6.10, 7.18

28. look-alike items must have distinctive labeling 5.13B, 5.21, 6.14, 7.5, 7.6,

Main Category: information errors Detailed category: misread, mismeasure, misinterpret

5.21

5.13B

28. look-alike items must have distinctive labeling 5.13B, 6.14, 7.5, 7.6, 5.21

Main Category: information errors Detailed category: misread, mismeasure, misinterpret

7.57.6

6.14

Thank you!