1. Mistake-proofing: improving the design of tools and tasks John Grout

3. Here are some photos of mistake-proofing solutions Mistake-proofing is the use of process design features* to facilitate correct actions, prevent simple errors, or mitigate the negative impact of errors. *these process design features can be referred to as “devices” or “counter-measures”

4. A discussion of the interaction of tools, tasks and people –SEIPS interventions where tools interact with task and person

5. A discussion of the interaction of tools, tasks and people Principal findings –Simplification (process mapping, visual systems (a.k.a. 5S)) –Designing benign failures to avoid errors –Facilitating correct action

6. Interaction of tools, tasks and people: Visual Systems Simple design changes that make compliance with IHI’s VAP Best practice bundle easy to check visually.

7. Interaction of tools, tasks and people: Designing Benign Failures Medical and non-medical examples see the difference?

8. Interaction of tools, tasks and people: Facilitating correct action

9. A discussion of the interaction of tools, tasks and people Challenges and remaining questions –Assessing FMEA recommended actions. How design-oriented is it? –Leveraging existing examples to reduce the creativity needed in design.

10. Translating What into How Error typology Solution typology Error Solution Abstract Concrete Examples Hinckley’s 18 error categories Hinckley’s 167 solution methods Your errors Your Solutions 150 Examples from book Misread, mismeasure, misinterpret information

11. Main Category: information errors Detailed category:misread, mismeasure, misinterpret 15make labels easy-to-read7.6, 7.7, 7.28 18eliminate transcriptions8.18 22distinguish related items by color (color coding)7.7 25 makes subtle distinctions obvious with organization and information7.7 26 38 use graphics to simplify or clarify complexity and make interpretation easy7.18 28 look-alike items must have distinctive labeling5.13B, 6.14, 7.5, 7.6, 5.21 (live strong) 30provide information in units needed (avoid conversions)7.1 32make location of supplies accuated and obvious8.18 34check for compliance to specification limits7.17, 8.14 40print a required dimension guide on the worksheet7.17 85processes are designed to be standard operations8.9 109automate the execution8.15, 8.18 135print information once6.10, 7.18

12. 28. look-alike items must have distinctive labeling 5.13B, 5.21, 6.14, 7.5, 7.6, Main Category: information errors Detailed category: misread, mismeasure, misinterpret 5.21 5.13B

13. 28. look-alike items must have distinctive labeling 5.13B, 6.14, 7.5, 7.6, 5.21 Main Category: information errors Detailed category: misread, mismeasure, misinterpret 7.5 7.6 6.14

14. Thank you!