Campbell School of Business
Berry College
Mistake-Proofing
Your System
Workshop on Best Practices
for Reducing Transfusion Errors
John Grout
jgrout@campbell.berry.edu
www.mistakeproofing.com
706-238-7877
John Grout
Mistake-Proofing
IS
• The use of process or design features to prevent
errors or their negative impact.
• Also known as Poka-yoke, Japanese slang
for
“avoiding inadvertent errors” which was formalized
by Shigeo Shingo.
• Inexpensive.
• Very effective for manufacturers that are aware of it.
• Based on simplicity and ingenuity.
• Something you already have in your organization.
Mistake-Proofing
IS NOT
• Rocket science.
• A stand-alone technique that will obviate the
need for any other responses to error.
• Widely known and practiced in manufacturing
(even less in services generally, or healthcare
specifically).
John Grout
Everyday Examples
John Grout
Mistake-Proofing
Tends to Be Very Effective
AT&T Power Systems: average outgoing
defects reduced by 70%
TRW: reduced customer PPM’s from 288 to 2.
Federal Mogul: 99.6% less customer
defects and 60% productivity increase
DE-STA-CO: omitted parts 800 to 10 ppm
all modes 40,000 to 200 ppm
15-30% productivity increase
John Grout
But Devices
Tend to Be Inexpensive...
Frequency of Occurrence
Cost
John Grout
$1000 or more
$250 to $1000
$100 to$250
Cumulative Proportion
$25 to $100
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
$25 or less
Proportion
Cost of Poka-Yoke Devices
The Paybacks Can Be Substantial
 Dana corporation has reported a $500,000 savings
resulting from a $6 device
 Ortho-Clinical Diagnostics (Johnson & Johnson) saved
$75000 annually by discovering a new use of Post-It®
notes
 AT&T Power Systems (Lucent Technologies) reported net
saving of $2545 per device (3300 devices)
 Weber Aircraft reports saving $350,000 during their first
year of implementation of approximately 300 devices.
 GE Aircraft Engines spends a minimum of $500,000 on
any in-flight shut-down (IFSD). Spending $10,000 to stop
one IFSD yields 50:1 benefit
John Grout
Example: Broselow Tape
John Grout
Example
 Error: esophageal intubation
(putting a tube into a patient’s
stomach which was intended for
their lungs)
 Poka-Yoke: Squeeze bulb and put on
tube. If bulb inflates, the tube is in
the lungs. If not, tube is incorrectly
placed in the esophagus.
John Grout
Healthcare Applications Are Different
than Manufacturing
 Both service provider and patient errors impact
service quality and must be managed
 The service provider is blamed for all errors, both
those committed by the server and by the patient
 traditional quality improvement methods may have
limited impact
In other services 1/3 of customer complaints relate
to problems caused by the customer themselves
Source: make your service fail-safe. Chase, R. B., And D. M. Stewart. 1994. Sloan management review
(spring): 35-44.
John Grout
 1998, John R. Grout
Server Poka-Yokes
Task
Treatment
Tangibles
 Task poka-yokes:

Doing work incorrectly or not requested, wrong
order, too slowly
 Treatment poka-yokes:

Lack of courteous, professional behavior
 Tangible poka-yokes:

Errors in physical elements of service
John Grout
Examples
Task
Treatment
Tangibles
 Task poka-yokes:


Cash register buttons labeled by item (instead of price)
Tags to indicate order of arrival
 Treatment poka-yokes:


Bell on shop door
Record eye color on bank transaction form (insure eye
contact)
 Tangible poka-yokes:


Paper strips around towels (indicate clean linens)
Envelope windows
John Grout
Preparation
Customer Poka-Yokes
Encounter
Resolution
 Preparation poka-yokes:

Failure to bring necessary materials, understand role,
or engage correct service
 Encounter poka-yokes:

Inattention, misunderstanding, or memory lapses
 Resolution poka-yokes:

Failure to signal service failure, provide feedback,
learn what to expect
John Grout
Preparation
Examples
 Preparation poka-yokes:


Encounter
Resolution
Appointment reminder calls
Student degree requirement checklist
 Encounter poka-yokes:


Height bar in amusement park
ATM using card swipe instead of insertion
 Resolution poka-yokes:

Provide premium for completed survey
John Grout
Mistake-proofing Puts
“Knowledge in the World”
In addition to “Knowledge in the Head”
Head:
World:
 “Improve” SOPs
(increasing complexity?)
 Retrain
 Re-certify skills
 Manage & enhance
attentiveness
 Provide clues about what to
do
 Change process design:
embed the details in the
process
 Frees mind to consider the
“big picture”
 Facilitates “knowledge
work”
John R. Grout
15
Knowledge in the World:
Which dial turns on the burner?
Stove A
Stove B
Knowledge in the World:
How would you operate these doors?
Push or pull? left side or right? How did you know?
A
B
John R. Grout
C
17
Knowledge in the World:
Whose signature is required?
Before:
After:
John Grout
No System of Barriers is Perfect…
Error
Harm
John Grout
Adapted from James Reason’s
Managing the Risk of Organizational Accidents
No System of Barriers is Perfect…
…But improvements can be made
Error
Error
Harm
Harm
John Grout
Adapted from James Reason’s
Managing the Risk of Organizational Accidents
Where do I go from here?
Mistake-Proofing Resources on CD
Instructions:
1. Put CD in drive (label facing up)
2. Close the drive (starts automatically)






These presentation PowerPoint slides
Full text book: Mistake-Proofing Designing Errors out by
Chase & Stewart (only service oriented book on the topic)
An annotated bibliography of other books
Resource links to the world wide web
A few medical examples and information on how to contribute
your organization’s examples.
Contact information
John R. Grout
21
Thank You!
John Grout