Mistake Proofing for Lean Healthcare

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Chapter 4

Basic Elements

oftheMistake-Proong

System

4.1 QUALITY AT THE SOURCE

With the mistake-proong system, we clearly recognize

that “to err is human.” The real problem is letting errors

turn into defects. At worst (but as is often the case), the

rst time we hear about a problem is when the patient

or customer complains. In effect, that patient or cus-

tomer becomes the “quality or safety inspector” who has

uncovered the defect, as shown in Figure4.1. A patient

or customer who has received a defective service or

product is 100 percent dissatised and perhapsharmed.

Allowing patients to become the “inspectors” of

healthcare services crea ...