Mistake Proofing – Dr. Tim Clapp and Susan McLean
December 9-12, 2008 - Register Now!

Future Course Offerings:
December 8-11, 2009 - Register Now!

Course Description :

Dr. Blanton Godfrey, Dean of the College of Textiles at NCSU, and lead faculty member Dr. Timothy Clapp have partnered with Professor Takeshi Nakajo from Chuo University Tokyo, Japan, and Susan McLean MSN RN, Healthcare Consultant, to create a systematic performance improvement methodology for the reduction of errors in manufacturing, transactions, and healthcare organizations.
Organizations across the nation are beginning to approach performance improvement methodologies that focus on the “prevention of error” but few have provided a systematic methodology that enables successful execution and long term results. The four components of the NCSU model for Error Proofing are:

• FMEA (Potential Failure Mode Effects Analysis) and HFMEA (VA Office of Patient Safety – Healthcare Failure Modes and Effects Analysis)
• Error Proofing Methodology and Solution Generation– NCSU Methodology and Database
• Solution Priority Matrix (SPN)
• Leadership Execution and Implementation

In the ideal world, there are no transaction errors, no faulty products, no unnecessary deaths and no unnecessary harm for patients. It is the vision of this team to integrate sustainable error proofing and solution initiatives throughout all organizations, in an effort to impact the quality and performance of any organization's subsystems, processes, or products

The first phase of Error Proofing begins by identifying the potential causes of errors in the process. Topics taught in Phase 1 include:

• Failures and Motion Failures
• Risk Assessment and Root Cause Analysis
• Failure Modes and Effects Analysis (FMEA)
• Healthcare Failure Modes and Effects Analysis (HFMEA)
• Provision of an In-depth review of Failure Modes: Process Failures, Selection Failures, Perception Failures,  Priority Number (RPN) and Hazard Scoring Matrix

The second phase of Error Proofing focuses on the fundamental error proofing model and the generation of a comprehensive set of proven solutions to eliminate or reduce the risk of errors. Topics taught in Phase 2 include:

• Professor Nakajo's Principles of Error Proofing
• Elimination
• Replacement
• Facilitation
• Detection
• Mitigation
• Accelerated Problem Solving using proven solution directions based on the Theory of Inventive Problem Solving (TRIZ)

NC State has developed the Error Proofing Solutions (EPS) Database that includes over 500 solutions to common errors in industry and healthcare. The EPS database will assist in the systematic generation of error proofing solutions to affect long-term change.

The third phase of Error Proofing provides a method of prioritizing and selecting solutions for implementation. Topics taught in Phase 3 include:

• Pugh Concept Analysis
• Solution priority number (developed especially for the error proofing model to link prioritized solutions directly to potential failure modes)

The fourth phase of the Error Proofing provides a strategy for developing an action plan for implementing error proofing solutions within an organization. Topics taught in the phase include:

• Action Plan Development
• Leadership Engagement
• Instituting High Team Performance across Healthcare organizations

Pre-requisites:

1. Review Current State Failure Mode Analysis within current organization
2. Come prepared to complete the four phases of the Error Proofing Model using an issue/mistake that you wish to error proof.  (For example, Omission error associated with a specific process)
3. Each participant will complete an error proofing case study and will present their results to the MBB group.

Software:

No software will be used for this course.