||Enabler ||Efforts to shape the norms and values of an
organization to focus on creating safety-conscious
behaviors and to commit significant
organizational resources to achieve patient and
||Enabler ||A subset of safety culture. Provides an open
environment—one in which errors are viewed as
opportunities to learn rather than events to be
punished—which encourages increased event
||Enabler ||Disclosing adverse events and errors that need
remedial action to prevent them in the future.
|Root cause analysis
||Enabler ||Identifies causes "that we can act upon such that
it meets our goals and objectives and is within our
Mistake-proofing cannot be done without a clear
knowledge of the cause and effect relationships in
|Corrective action systems
||Area of opportunity ||Policies and procedures that ensure causes of
events are properly resolved and remedial actions
||Area of opportunity ||Those efforts in which the special focus is on
particular outcomes or events, including falls,
nosocomial infections, medication errors, and
||Area of opportunity and venue for validation ||Builds correct, conditioned responses; provides a
laboratory for identifying and validating the
effectiveness of mistake-proofing projects.
||Subset ||Includes bar coding, computerized physician
order entry (CPOE), and robotic pharmacies;
expensive, complex, more technologically
sophisticated version of mistake-proofing.
||Complementary or a subset ||Using building layout and design to put
knowledge in the world is effective but difficult
with large, long-lived existing infrastructure.
|Revise standard operating procedures (SOPs)
||Competing or complementary ||Choosing to lengthen SOPs or increase their
complexity is an easy but often ineffective
alternative to mistake-proofing.
Simplifying processes and providing clever work
aids can complement or border on being mistake-proofing.
||Competing (partially) ||Mistake-proofing can reduce the need for some
aspects of attentiveness; it frees staff members to
attend to more important issues that are more
difficult to mistake-proof.
|Crew resource management (CRM)
||Complementary ||Some mistake-proofing devices reduce the need to
attend to process details. This reduced cognitive
load can free resources and facilitate effective
participation in decisionmaking typical in CRM.
|Failure modes and effects
analysis (FMEA) or failure modes,
effects, and criticality analysis
||Area of opportunity design tool || FMEA and FMECA identify and prioritize improvement efforts. Effective FMEA requires actions that lead to redundancy or mistake-proofing.
|Fault trees/probabilistic risk
||Area of opportunity design tool ||Identify all known causes of an event and the
probabilities of their occurrence. This is vital
information in creating informed design decisions
about mistake-proofing devices. A non-traditional
application of this tool is presented in Chapter 3.