Have you ever struggled with a gas nozzle that didn't fit, only to find it was for the wrong type of fuel? Or have you ever tried to add one last item to a running washing machine only to be confronted by a locked door? These and countless other mundane experiences are the result of error-proofing potentially dangerous or destructive equipment we use on a daily basis. Under the Toyota Production System developed in the 1960s, Shigeo Shingo used the term "poka-yoke," which means "avoid mistakes." This concept is now an integral part of many efficiency and safety systems: Planning for errors and designing ways to prevent them. In today's post, we'll explore how the concepts of poka-yoke could be applied to infection prevention.
When error-proofing infection control, we must first accept that, despite every effort, people make mistakes. Either from fatigue, time pressures, or poor professionalism, healthcare workers will inevitably miss a hand washing opportunity; environmental services will miss a surface; or a visitor will neglect to wear personal protective equipment (PPE). If we can start with the acceptance that errors are going to happen, then we can plan ways to prevent harm to patients when these errors occur.
Once we accept that inevitability, we can start to break down the probable mistakes and begin to error-proof them. There are two approaches to error-proofing: Control and Warning. Control creates a physical or mechanical barrier to performing the procedure incorrectly. An example would be designing an environmental services cart so that only the correct disinfectants fit in the desired slots. Or a sterile tray for inserting a central line could organize instruments in a way that forces the user to open them in the desired order. Warning uses color, sound, lights or other sensory input to alert the healthcare worker (HCW) that they are about to make a mistake. For example, recent advances in hand hygiene monitoring systems provide HCWs with a digital sensor that reminds them when it has been too long since they have washed their hands. Making PPE highly visible, such as mounted on the doors to patient rooms, remind everyone to don gloves and gown before entering.
So how can someone apply poka-yoke to their facility? Here are the steps:
1. Identify one error you want to prevent. Be as specific as possible: "HCWs will change gloves after every touch" rather than "HCWs will wear gloves whenever necessary."
2. Determine why the error happens. Is it because it is a new protocol and HCWs need to get used to it? Is it because gloves are located far from the HCW? Is it because there is weak buy-in to why this protocol is necessary?
3. Review how HCWs are currently informed of the requirement and how compliance is measured. This is your base line.
4. Identify deviations from this protocol. You will need to know as much as you can about the circumstances around non-compliance. This is not the root cause, this is the actual compliance.
5. Hypothesize and test different error-proofing ideas. Try out one idea at a time and measure for success. Include the HCWs in giving you feedback.
Advances in medical device design have helped avoid many errors, including in the infection prevention arena. Consider bandages that change color when bacteria is present, endoscope reprocessing techniques that prevent skipping steps, and even automatic toilet lids that close before flushing. The ever-present threat of ambient bacteria has been a difficult barrier to overcome, since avoiding transmission from contaminated surfaces has relied so much on human compliance with handwashing and cleaning protocols, which are notoriously prone to non-compliance. One recent advance is the use of biocidal materials, such as copper and copper-infused polymers, which continuously kill bacteria without the need of additional human processes. Their ability to maintain bacteria levels in the benign zone (low enough levels to keep patients safe) provides an excellent form of poka-yoke that positively impacts every aspect of infection control. What other error-proofing have you seen in your facility? Share your experiences below!
