Page 1 of 1

Figure 3-14

Mistake-Proofing the Design of Health Care Processes -

Figure 3.14. Generate alternative mistake-proofing device designs that will create the benign failure

Flow chart depicts mistake-proofing tools to identify resources available to create the benign failure. The chart is divided into three sections: Enabling tools, Design tools, and Implementation tools. 'Enabling tools' lists five functions: Process mapping, Just culture, Event and near-miss reporting, Root cause analysis, and Visual systems (5S). 'Design tools' lists six functions, each leading to a 'Brainstorm' function, then to a filter which evaluates the number of possible solutions arising from the 'Brainstorm.' If the Brainstorm yields at least the desired number (n) of solutions, then the flow continues on to the function labeled 'Solution Set.' If 'n' is less than the desired number of solutions, then the flow continues to the next function. In sequence, the design tools functions are: Failure modes and effects analysis (FMEA); Fault tree analysis; Multiple fault tree analysis; TRIZ (the acronym for the 'theory of inventive problem solving' translated from Russian), which is highlighted for emphasis; Weaker cues; and Change focus or give up (last function, yielding zero solutions), which returns to 'Brainstorm'. In each case, 'Brainstorm' activity resulting in solutions greater than or equal to 'n' continue to the 'Solution set' function, which then continues to the final section, 'Implementation tools.' The 'Implementation tools' section is described: 'Lots of tools, but beyond the scope of this book.'

*The variable n equals the number of solutions you would like to generate before selecting the best one.
**TRIZ is the acronym for the "Theory of Inventive Problem Solving" translated from Russian.

Return to Document

 

Current as of May 2007
Internet Citation: Figure 3-14: Mistake-Proofing the Design of Health Care Processes -. May 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/mistakeproof/mistakefig3-14.html