Visual Controls

Preventable medical errors are estimated to kill 100,000 to 440,000 people per year in the U.S. and similar levels of harm due to medical errors have also been observed in other countries. In order to effectively eliminate errors, we must first be able to recognize and report them and different types of error reporting are described. Secondly there must be a culture in place that deals fairly with errors by differentiating systems errors from individual human errors. This can be accomplished by applying a Just Culture. Additional tools for eliminating errors and improving processes are introduced including: the Pareto Chart, Failure Mode and Effects Analysis (FMEA), an expanded Plan, Do, Study, Adjust cycle, and the A3 form. There are 6 levels of error proofing and their effectiveness in preventing errors from reaching patients is assessed using clinical examples. Visual controls can be helpful for reducing errors and for following the progress of work process improvements. In the final video the major topics covered in this course are summarized, and a new name for TPS or Lean adapted to healthcare is proposed: Patient-centered Healthcare Delivery System (PHDS). This name emphasizes the importance of applying the scientific method, like PhDs, to continually improve healthcare delivery while always focusing on the needs of patients.

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