July 2017
Intermediate to advanced
111 pages
3h 27m
English
Content preview from Mistake Proofing for Lean Healthcare
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CHAPTER 6
6.3.7 Shrink-Wrapping on Dangerous Medications
Figure6.12 shows an example that combines visual and tactile
cues in a contact or identication poka-yoke. Medications
that can cause paralysis are shrink-wrapped with a bright red
cover. This poka-yoke visually alerts the person administer-
ing the medication that it is dangerous. It also requires the
person to physically remove the label, a tactile signal that
takes time to perform and is even more difcult to overlook.
Other ways to prevent medication confusion include bar
coding as well as using labels to clearly distinguish the
names of look-alike or sound-alike drugs (e.g., cefT
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