Lean Management System ◾ 113
Poka-Yoke “Poka-yoke” is a Japanese term that means “mistake-proofing” or “inadvertent error prevention.” The key word in the second translation, often omitted, is “inadvertent.” It is also referred to as “error-proofing.” Some have described it as a system that allows employees to immediately catch any mistake so it can be corrected. Organizations pay a hefty price when mistakes reach the customer. The aim of poka-yoke is to design processes so mistakes are prevented or corrected immediately, thus eliminating defects at the source. Often, mistake proofing is accomplished by providing barriers that prevent people from taking the wrong action. Poka-yoke has been used in healthcare to prevent life-threatening mistakes. There are many examples in healthcare where mistake proofing through poka-yoke has been applied to medical devices. Human errors and faulty medical devices can threaten the safety of patients; poka-yoke techniques, used with employee training, can reduce the chances of these errors. Technology has become a powerful ally in the battle against mistakes and errors in healthcare. The Agency for Healthcare Research and Quality has provided a catalog of poka-yoke examples in healthcare, as follows: ◾◾ Infant Abduction Prevention: With the aid of electronic sensor technology, an electronic device, or “tag,” is clamped to the infant’s umbilical cord. The tag ensures that the infant is not removed from the nursery. If the infant is removed without authorization, alarms sound, specified doors lock, and the elevators automatically return to the secured maternity floor. The elevator doors remain open. ◾◾ Patient Identification and Safety: Bar coding has been very effective in reducing certain types of mistakes in healthcare. Healthcare facilities have used bar coding to ensure a match between patients and their treatment, medicines, and supplies. Practitioners have emphasized the importance of radiologists matching the film they are reading to the right patient and how bar coding has been useful in that regard. Bar codes are attached to every order so the radiologist can electronically identify the patient and ensure the correct patient (information) has been entered into the digital dictation system. Bar coding has also been used to combat the problem of mislabeled specimens. Each specimen is labeled with a bar code specific to the patient and the test ordered. The instruments in the laboratory are programmed to identify the bar code
