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Figure 3-5

Mistake-Proofing the Design of Health Care Processes -

Figure 3.5. "Won't Connect? Don't Connect!"

Safety poster to prevent Medical Gas Mix-Ups. The poster reads, 'Take a look before you hook. Check the label for (sample label): Oxygen, Refrigerated Liquid USP UN 1073, with a warning sign for Oxygen 2. Won't Connect? Don't Connect! Never use adaptors. Never change fittings.'

Here is where a "safety culture" is needed for mistake-proofing. If users do not understand that the process is communicating important information to them, they may try to override the protections provided by the process.

Source: Medical Gas Mix-Ups. Food and Drug Administration, Center for Drug Evaluation and Research. http://www.fda.gov/cder/dmpq/medgas_mixup/default.htm.

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Current as of May 2007
Internet Citation: Figure 3-5: 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/mistakefig3-5.html