Mistakeproofing: improving the design of tools and tasks

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Mistake-proofing improving the design of tools
and tasks

• John Grout

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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
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A discussion of the interaction of tools, tasks
and people

• SEIPS interventions where tools interact with
  task and person

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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

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Interaction of tools, tasks and people Visual
Systems

• Simple design changes that make compliance with
  IHIs VAP Best practice bundle easy to check
  visually.

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

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Translating What into How
Abstract Concrete
Solution typology
Error typology
Examples
Error
Solution
Hinckleys 18 error categories
Hinckleys 167 solution methods
Your errors
150 Examples from book
Your Solutions
Misread, mismeasure, misinterpret information
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Main Category information errors Detailed
category misread, mismeasure, misinterpret
28. look-alike items must have distinctive
labeling 5.13B, 5.21, 6.14, 7.5, 7.6,
5.13B
5.21
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Main Category information errors Detailed
category misread, mismeasure, misinterpret
6.14
28. look-alike items must have distinctive
labeling 5.13B, 6.14, 7.5, 7.6, 5.21
7.5
7.6
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Thank you!