Many of you have already been familiar for several years with John Groutís website on mistake-proofing. Well, he has now put together a monograph Mistake-Proofing the Design of Health Care Processes that is available on the AHRQ website. There is also an AHRQ podcast with Dr. Grout discussing mistake-proofing in healthcare.
The most effective interventions we recommend in our root cause analyses (RCAís) are usually forcing functions or redesign of processes and equipment to direct one toward the most appropriate action. There are several examples in our Tip of the Week Archive. Groutís monograph provides numerous examples of using the principles of mistake-proofing to either avoid errors or to have errors result in more benign outcomes.
He begins with an overview of general mistake-proofing, human error, use of FMEA and CRM, and current state of patient safety activities. He points out that mistake-proofing is generally inexpensive and has a good ROI (return on investment). He also talks about the limitations and potential unintended consequences of such redesign efforts. He then presents numerous real-life examples of mistake-proofing implemented at various healthcare facilities around the country.
Overall, this is an excellent monograph that has many practical examples you may wish to implement in your patient safety activities. It will also help you in developing your own solutions to potential problems in your facilities. This is a nice complement to Donald Normanís classic text on using design to prevent the wrong actions (Norman DA, The Design of Everyday Things. New York: Doubleday; 1989 - also in paperback from Basic Books 2002).