Human errors happen. But in the healthcare world, one easy mistake could mean the loss of a life. The answer? Gotta catch ‘em all (or prevent ‘em all) before they happen.
While Pokémon Go has captivated the world’s attention lately, “poka yoke” is a Japanese system of mistake-proofing that has been around since the 1960s. Leveraged by the Toyota Motor Corporation, poka yoke hardwires processes and prevents inadvertent human errors.
As Dr. Debora Simmons recently shared with providers during a live webinar, human errors are inevitable. In her example, Dr. Simmons discussed medical tubing connectors and how their misconnections can result in serious injury or death. Think about a USB connector: it only fits one way to make sure it works without damaging your computer.
So what has happened in the last ten years to address this safety hazard?
The good news is that every major safety organization supports changing the standards across all connectors to create more of a poka yoke environment. The Association for the Advancement of Medical Instrumentation (AAMI) recognized the need for action and brought expert groups together internationally to change these standards.
A communications program by the Global Enteral Device Supplier Association (GEDSA), the Stay Connected initiative, was launched to help facilitate the introduction of new connectors, starting with enteral devices.
The Federal Drug Administration is also working with these professional groups to support the correct use of new connectors to reduce the risk of tubing misconnections.
Safety organizations are not the only groups to get involved. Many providers have also taken a proactive approach, and physician engagement coupled with updated processes has been paramount in preventing potentially fatal mistakes.
Despite new federal regulations and design modifications, people are still dying from this error—and from other human errors in medicine. Health system leaders coupled with new innovative technologies and updated expert guidelines will continue to drive improvements and mistake-proofing in healthcare, ultimately preventing more unnecessary incidents.
Want to learn more about preventing harm in healthcare? Check out the recent slides from July’s Advisor Live: Transitioning to ENFit Connectors: A Safer Enteral Feeding System or visit the Premier Safety Institute website.
P.S. Have patients, guests and staff playing Pokémon GO? Make sure they stay out of the surgical suite!