Mistake Proofing for Lean Healthcare: 1st Edition (Paperback) book cover

Mistake Proofing for Lean Healthcare

1st Edition

Edited by Samuel Carlson, MD, Maura May

Productivity Press

111 pages | 146 B/W Illus.

Purchasing Options:$ = USD
Paperback: 9781439837436
pub: 2015-09-03
SAVE ~$6.39
Hardback: 9781138431928
pub: 2017-07-27
SAVE ~$41.00
eBook (VitalSource) : 9780429257179
pub: 2017-07-27
from $15.98

FREE Standard Shipping!


The principles of mistake proofing, long used to eliminate errors and defects across a range of industries, are now being applied in healthcare organizations around the world to help ensure patient safety, improve services, and eliminate waste.

Mistake Proofing for Lean Healthcare is based on the definitive mistake-proofing philosophy and system developed by Shigeo Shingo. This reader-friendly book introduces the main concepts and benefits of mistake proofing in healthcare and highlights common reasons that errors and defects occur. It also explains how to catch errors before they become defects, using the concept of "source inspection," so you can ensure quality before a process is performed instead of afterward. When systematically used, the mistake-proofing approach explained in this book will help you:

  • Create safer, more reliable, and more effective healthcare services for both patients and staff
  • Establish a culture in which mistakes and the conditions that cause them are readily surfaced so they can be corrected
  • Lay the foundation for processes that flow smoothly, without disruption
  • Eliminate rework, waste, and the need for extra resources and supplies

Presenting real-world healthcare examples, the book shows different types of mistake-proofing devices and methods (poka-yoke) that provide feedback quickly and automatically to prevent errors and defects.

The book is part of the Lean Healthcare Series and is designed for individual or group learning. Each chapter includes reflection questions to facilitate understanding and stimulate discussion and action.

Table of Contents

Getting Started

Purpose of This Book

What This Book Is Based On

Two Ways to Use This Book

How to Get the Most Out of Your Reading

Become Familiar with This Book as a Whole

Become Familiar with Each Chapter

Using a Reading Strategy

Using the Margin Assists

Overview of the Contents

Chapter 1: Getting Started

Chapter 2: The Production Processes and Operations of Healthcare

Chapter 3: Introduction to Mistake Proofing

Chapter 4: Basic Elements of the Mistake-Proofing System

Chapter 5: Using Poka-Yoke Systems

Chapter 6: Examples of Poka-Yoke Applications

Chapter 7: Reflections and Conclusions

The Production Processes and Operations of Healthcare

The Industrial Origins of Lean Healthcare

Production, Process, and Operation

Principles of Lean Healthcare Management

Standard Work


Flow Production


Socratic Method



Introduction to Mistake Proofing

What Is Mistake Proofing?

Why Focus on Zero Defects?

How Mistake Proofing Makes Work Easier

What Causes Defects?

Communication Errors

Cognitive Errors

Red-Flag Conditions

Controlling Conditions So Defects Do Not Happen

The Traditional Quality Improvement Cycle

Integrating PDCA in the Mistake-Proofing Approach



Basic Elements of the Mistake-Proofing System

Quality at the Source

The Four Elements of Mistake Proofing

Three Approaches to Inspection

Judgment Inspections Reveal Defects

Informative Inspections Reduce Defects

Statistical Quality Control

Successive Checks


Source Inspection Keeps Errors from Becoming Defects

100 Percent Inspection Catches All Errors

A Short Feedback Loop Means Quicker Action on Problems

Poka-Yoke Systems Catch Errors We Might Have Missed



Using Poka-Yoke Systems

About Poka-Yoke Systems

Poka-Yoke Systems in Source Inspection and in Informative Inspection (Self-Checks and Successive Checks)

How Poka-Yoke Systems Regulate the Process

Types of Poka-Yoke Systems

Method Poka-Yokes

Checklists in Healthcare

Using Checklists Effectively

Stop the Line—Stop the Process

Physical Poka-Yokes

Contact or Identification Techniques

Fixed-Value or Number Techniques

Motion-Step or Sequence Techniques

Poka-Yoke Sensors

Devices that Link to Poka-Yoke Sensors



Examples of Poka-Yoke Applications

Learning from Examples of Poka-Yoke Applications

Method Poka-Yoke Examples

Thoracic Surgery Checklist

Red Event Safety Alert, Incident Command Checklist

Chart Preparation Checklist

Rounding Checklist

Clinician Previsit Checklist

Electronic Health Systems

Contact or Identification Poka-Yoke Examples

Integrated Color-Coding Systems

Other Color-Coding Poka-Yokes

Wristbands with Bar Codes or Radio-Frequency Identification Tags

Tactile Signals on Wrong Buttons

Throat Pack Identification

Shrink-Wrapping on Dangerous Medications

Fixed-Value or Number Poka-Yoke Examples

Surgical Sponge-Counting Systems

Automatically Timed Processes

Automated External Defibrillator

Bed Angle Visual Aid

Pulse Oximeter

Motion-Step or Sequence Poka-Yoke Examples

Oral Care Pegboard

Glucose Test Reminder

Hand Hygiene Monitoring Systems

Sheathed Needles



Reflections and Conclusions

Reflecting on What You Have Learned

Applying What You Have Learned

Possibilities for Applying What You Have Learned

Your Personal Action Plan

Opportunities for Further Learning



About the Editors

Tom Jackson is the former CEO of Productivity, Inc. and Productivity Press and member of the influential Ford Lean Advisory Group.

About the Series

Lean Tools for Healthcare Series

Learn more…

Subject Categories

BISAC Subject Codes/Headings:
BUSINESS & ECONOMICS / Quality Control
BUSINESS & ECONOMICS / Industries / Service Industries
MEDICAL / Administration