“To err is human,” is the famous quote credited to Alexander Pope in the 1700s. As humans we are destined to make mistakes. Daily, many of us will experience or actuate an error of some kind or shape; most of which are harmless or sometimes comical, like wearing two different colored socks.
There is plenty of research out there that explains the genesis and types of errors. We know that many errors are based on skill, knowledge, or the lack thereof, but most often these errors are rooted in the systems around us, the design of those systems, or the environment in which we work within these systems. So, it should not be a surprise that we will always recommend taking a comprehensive improvement principle- and systems-based approach for the most significant and sustainable impact.
However, we also know that the concept of error proofing alone can provide targeted and measurable improvement in patient harm. Sometimes by starting small and working through the steps of error proofing (which read very similar to an A3), you may find yourself starting to address some of the larger, fundamental root causes.
Let’s walk through the example of a patient fall in a hospital inpatient unit and what steps you could follow to error proof this scenario.
1. Identify the location of the defect
The first step to error proofing is to identify the location of the defect. In this situation the fall occurs inside the patient’s room.
2. Review the current standard operating procedure
Next you need to review the current standard processes surrounding this problem. For example, this hospital has already developed a falls protocol that outlines nine key elements to help prevent falls including, conducting a comprehensive fall assessment, providing non-slip socks, and utilizing bed alarms.
3. Identify the deviations from the standard
Just because a standard exists does not mean it is always utilized. Doing some observations and collecting data on deviations to a standard can shine light on opportunities for improvement and error-proofing. In this scenario, the staff were often forgetting to put the traction socks on the patient.
4. Determine the root cause
There could be many causes for a defect or problem but determining the root causes will help you later in determining the best solution. There are multiple ways of doing this, one being asking “5 whys” and utilizing a root cause tree. You may need to prioritize which root cause to address first. In this case, it was discovered that the non-slip socks were located down the hallway in a clean storage room meaning the staff would have to leave the room to get them and then often get distracted in the process.
5. Identify the best type of error proofing to address the root cause
There are three different types of error proofing: elimination, replacement, and facilitation. Each serve different purposes. In this situation, it is hard to eliminate the problem as it still relies on human memory and action; however, we can help the humans involved reduce the opportunity for this error by making it easier to complete this important step.
6. Create a solution and test for its effectiveness
For this example, the non-slip socks are now going to be included in the patient welcome packet that each patient receives upon admission. This facilitates the socks being available in the room where the staff needs them and reminds the staff to instruct the patient about putting them on and other fall prevention tactics.
Remember, testing for the effectiveness of a solution is equally as important. Use observations and data to see if the solution is actually working to ensure all patients are wearing the non-slip socks, which should lead to a reduction in falls caused by this error.
Yes, to err is a part of being human, but we also know we can take steps to reduce and prevent errors. In the past few decades, errors in healthcare have been brought to the forefront of discussions in the media and in organizations. This was accelerated when the Institute of Medicine published the books To Error is Human and Crossing the Quality Chasm which shined a spotlight on the magnitude of the problem and challenged all of us to find ways to systematically reduce and eliminate harm to our patients.
To learn more about error-proofing in healthcare, check out the new self-paced course.
Tools for Improvement course in Catalysis Academy