Poka YokeMistake Proofing

Col. Dr. Jamal Hommadi

Quality Week 2014

بسم الله الرحمن الرحيم

PURPOSE

Introducing Poka yoke as one of the effective quality design techniques experienced in manufacturing business to the quality of healthcare.

Introduction• It has been more than 15 years since the Institute

of Medicine (IOM) released its landmark report, To Err Is Human,

• Building a Safer Health System, which galvanized attention on the serious and pervasive problem of errors in health care.

• Research into the causes of medical errors and ways to prevent them increased dramatically in the ensuing years after publication of the IOM report in 1999.

Introduction

The Joint Commission commented that:

“it assumes that no matter how knowledgeable or careful people are, errors will occur in some situations and may even be likely to occur.”

Introduction

Traditional quality control methods identify “variation” as the enemy.

Recent experience has shown that mistakes are the most common cause of problems in health care as well as in other industrial environments.

The best methods for controlling variation and complexity, is by mistake proofing.

Introduction

•Shingo did make a clear distinction between a mistake and a defect.

•Mistakes: are inevitable; people are human and can not be expected to concentrate on all the time, or always to understand completely the instructions they are given.

•Defects: result from allowing a mistake to reach the customer, and are entirely avoidable.

World of Mistakes

MISTAKES:

they are inevitablepeople are human and can’t

beexpected to concentrate

on the work in front of them100% of the time

DEFECTS:

Defects are a direct result of allowing a mistake

to reach the customer defects are entirely

avoidable

*

*

taken from the book, Shingo 1986 p.50

T0 Err Is Human!

The Institute of Medicine2 estimated in 1999 that between 44 000 and 98 000 people die in hospitals each year due to mistakes, and that medical mistakes are the 8th top killer in the nation.

In the same report hospital errors alone have also been estimated to cost the nation $8.8 billion a year.

VARIATION: A SOURCE OF DEFECTS

MISTAKESTHE MAJOR SOURCE OF

DEFECTS

What is Poka-Yoke ( ポカヨケ ) ?

Poka-Yoke was coined in Japan during the 1960s by Eng. Shigeo Shingo who was

one of the industrial engineers at Toyota.

 is a Japanese term that means "mistake-proofing". avoid (yokeru) mistakes (poka).

definition

Mistake-proofing: is the use of process or design features to prevent errors or the negative impact of errors.

Mistake proofing is also known as poka-yoke (pronounced poka-yokay), Japanese slang for “avoiding errors.”

-Shigeo Shingo said:

“Preventing the act of forgetting what you

have forgotten”

Why is “Poka-Yoke” an Important Concept?

•Maintain Customer Satisfaction & Loyalty

• There is always a cost associated with defects!

Mistake-Proofing Approaches

There is no comprehensive typology of mistake-proofing. Tsuda lists four approaches to mistake-proofing:1. Mistake prevention in the work environment.2. Mistake detection (Shingo's informative inspection).3. Mistake prevention (Shingo's source inspection).4. Preventing the influence of mistakes.

Tsuda's approaches are similar to those recommended by the Department of Health

and the Design Council in England:

1. Prevent user error from occurring.

2. Alert users to possible dangers.

3. Reduce the effect of user errors.

Human Error

Rasmussen and Reason divide errors into three types, based on how the brain controls actions:

1.skill-based actions.

2.rule-based actions.

3.knowledge-based actions.

Their theory is that the brain minimizes effort by switching among different levels of control, depending on the situation.

skill-based actions.• Common activities in routine situations are

handled using skill-based actions, which operate with little conscious intervention.

• These are actions that are done on “autopilot.”

• Skill-based actions allow you to focus on the creativity of cooking rather than the mechanics of how to turn on the stove.

• Errors that occur at the skill-based level are comparable to Norman's concept of slips.

Slips

Rule-based actions

• utilize stored rules about how to respond to situa tions that have been previously encountered.

• When a pot boils over, the response does not require protracted deliberations to determine what to do.

• You remove the pot from the heat and lower the temperature setting before returning the pot to the burner.

Knowledge-based actions

• When novel situations arise, conscious problem solving and deliberation are required.

• KBA are those actions that use the process of logical deduction to determine what to do on the basis of theoretical knowledge.

• Every skill- and rule-based action was a knowledge-based action at one time.

few of the many possible nurses errors

• Nurses could inadvertently select the wrong medication, misread the prescription, select the wrong dose, deliver the medication to the wrong patient, select the wrong number of capsules or pills, or inadvertently drop a pill without detection.

• Bates et al14 stated that 6.5% of the patients entering hospitals experience adverse drug effects due to prescription errors.

• Lapworth and Teal cited two studies where clinical laboratory mistake rates were in the range of 0.3–2.3%. Pellar et al found that mistakes were a leading source of delays.

• The Harvard Medical Practice found that 3.7% of hospital patients received disabling injuries due to medical treatment errors and 58% of these injures were caused by errors in management.

• The Quality in Australian Health Care reported that 16.6% of hospital admissions were associated with adverse events of which, 50% were highly preventable.

Knowledge in the Head vs.

knowledge in the World• Norman divides knowledge into

two categories:

• 1. Knowledge in the head: is information contained in human memory.

• 2. Knowledge in the world: is information provided as part of the environment in which a task is performed.

knowledge in the World

•oxygen and nitrous oxide.

Concealed

Partially apparent

completely

apparent

The domino theory of accident causation adapted from Bird (1974)

safety/loss of control

Basic causes

intermediate

causes

accident causes

Injury problem

Safety / loss of control

Basic causes

intermediate causes

accident causes Injury or

problem

“The occurrence of an [accident] is the culmination of a series of events or circumstances, which invariably occur in a fixed

and logical order”

(Heinrich et al.,1980)

Poka Yoke at HR

Do we have a standardized and efficient hiring process?

Are We Hiring People Who Will Thrive in a Lean

Culture and Contribute to Our

Success?

Example: MMU• Medication is placed in order of the MAR

(Medication Administration Record) so it is easy to find and

Example from Lab.

Red specimens = Hospital registered

Patient (stat) Green specimens =

(Routine)mixed up

Tube racks color coded so that they do not get

mixed up

Reminders

This sign reminds staff to send a report at the certain time of a day

Prevention

• NG Tube - Shows how NG tube cannot be connected to an IV port

Prevention

• A single action one hand sharps protection to prevent the user from

• being poked

Prevent error

• Pre-mix scald anti-scald valve

Detect error

Infant abduction sensor locks the exit in case of an abduction

Esophageal intubation detector

Sign your site

• The holes for the pins are located at 12

• o’clock and 5 o’clock. Also, the oxygen outlet is

• green, and the medical air outlet is yellow.

• The medication dispenser dispenses medications and detects when they are removed.

• Clearly visible sinks encourage handwashing.

• Handrails are present from the bedside to

• the bathroom.

Standardized headwalls allow staffmembers to work on 'auto-pilot'.

• A patient's medical records can be stored

• in this wristband.

Wristbands can contain color photos,

symbols, and other patient information

• “Decoupling” means separating an error-prone activity from the point at which the error becomes irreversible.

Tools

• Just Culture: refers to a working environment that is conducive to “blame-free” reporting but also one in which accountability is not lost.

• Root cause analysis (RCA) is a set of methodologies for determining at least one cause of an event that can be controlled or altered so that the event will not recur in the same situation.

•FMEA and FMECA are “virtually the same,” except for a few subtleties that have been more or less lost in practice (hereafter simply referred to as FMEA). These two related tools enable teams to analyse all of the ways a particular component or process can fail, predict what the consequences of that failure would be, and prioritize remedial change actions.

• A fault tree is a graphical representation of the relationships that directly cause or contribute to an event or failure.

•Fault trees are a top-down approach. A fault tree starts with an event and determines all the component (or task) failures that could contribute to that event.

Knowing What Errors Occur, and Why, Is Not Enough

The golden role of thumb in Poka yoke is that:

1.Knowing errors is not enough.

2.Do not accept errors.

3.Do not do errors.

4. do not pass errors.

5.Redesign the process that causes errors.

Don’t accept a defect

Don’t do a defect

Don’t pass on a defect

Your supplier

Your customerYou

An error proofing system should consider

these 3 simple rules

JCI provides three questions that must be answered at the “redesign the process” step:

1. How can we change the process to prevent this failure mode from occurring?

2. What design/redesign strategies and tools should we use? How do we evaluate their likely success?

3. Who should be involved in the design/redesign process?

Conclusion• Implementing mistake-proofing in medical

environments will probably be more challenging and difficult than implementing the same techniques in manufacturing.

• The difficulties are not provided as excuses or reasons why mistake-proofing should not be implemented but rather as guides to what can be expected as implementation progresses.

• mistake-proofing will fit into a variety of existing efforts to improve patient safety.

…We are human and humans err. Despite outrage, despite grief, despite experience, despite our best efforts, despite our deepest wishes, we are born fallible and will remain so. Being careful helps, but it brings us nowhere near perfection…The remedy is in changing systems of work. The remedy is in design. The goal should be extreme safety. I believe we should be as safe in our hospitals as we are in our homes. But we cannot reach that goal through exhortation, censure, outrage, and shame. We can reach it only by commitment to change, so that normal, human errors can be made irrelevant to outcome, continually found, and skilfully mitigated.

Donald Berwick (IHI) said:

Conclusion