by adgrooms on January 8, 2020

We all make mistakes. In healthcare, mistakes can have consequences that can vary from losing a few seconds of time to affecting patient outcomes. In hindsight, many mistakes can be avoided, and better procedures are implemented to avoid making the mistake again. In the ongoing effort to eliminate mistakes and provide a better quality of care, sometimes it is beneficial to borrow processes from other industries to help improve healthcare. While talking to a family friend over the holidays, he was telling me about his job as a poka-yoke implementer for Toyota. The more I learned about poka-yoke, it sounded like a perfect fit for healthcare.

Poka-yoke is a Japanese term for mistake-proofing and is basically making a process foolproof or unbreakable. It is originally a manufacturing idea formalized and implemented into the Toyota Production System, where my friend works. Basically his job is to try to break things, then figure out how to revise the process so mistakes can't happen. Processes are developed using testers that try to make mistakes deliberately. The process is improved and iterated until all paths to a mistake are eliminated through the excellent design of the process. An equipment operator is unable to make mistakes because of the process put in place.

One example is the different sizes of gas vs diesel nozzles at the fuel pump. Instead of being able to make the mistake of putting the wrong fuel in your car, the fact that you can't put the wrong nozzle into the tank and ruin your engine is a poka-yoke. A square peg can't fit in a round hole. From my own experience; I had to change the low beam light bulb on my Toyota Prius yesterday. At the auto parts store, I bought the low beam bulb and went about changing it in the parking lot. I was unable to plug it into the socket. I looked at the old bulb and it didn't match, even though I know I bought the right bulb. It turns out I was trying to put the low beam bulb into the high beam socket by mistake, and the connector was different to prevent mixing up the bulbs.

Healthcare presents special challenges where judgment and individuality are involved. A physician performing procedure may use a pre-assembled package of instruments. All of the needed instruments will be there without fail, but the physician may not need to use them all. Poka-yoke processes can be found in many other instances in healthcare. Scanning wristbands and vocally confirming the name of the patient before surgery prevents mixups. Alerts in prescription software prevent bad drug combinations, although this depends on having correct and complete information in the system. There are numerous instances of poka-yoke in medical equipment, making procedures more accurate and efficient by removing instances of improper use. The key is to prevent mistakes before they are made.

Sometimes implementing a poka-yoke process involves adding another step for clinicians, which is not ideal given that physicians are already flooded with administrative processes and procedures. One example of this is EHR alerts. They can be helpful in preventing mistakes, but if the clinician is bombarded with nit-picky alerts that have little value or are redundant, it can be a source of unneeded stress. Careful analysis may be needed to determine if a poka-yoke is adding enough value to justify the extra time it takes from a clinician. Sometimes unnecessary or overused poka-yokes can result in workarounds and shortcuts to save time. In this case, an excellent process has not been reached yet, and further refinement is needed. The ideal result is when the poka-yoke fits seamlessly into the workflow, or even making the workflow better, benefiting everyone involved.

Poka-yoke is a good way to improve safety and reduce mistakes. (and it's fun to say) Do you see ways in your institution that poka-yoke can be implemented that prevents mistakes AND improves efficiency?