Mistake-proofing the Design of Health Care Processes. Figure 3.5

You Are Here: AHRQ Home > Medical Errors & Patient Safety > 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.

Return to Document