Overview
Background
Six Principles of Mistake Proofing Care
Summary

Detection

Detection is the process of catching anomalies/deviations and correcting them as soon as they are noted. Anomalies can occur in what is done, what fails to be done, or when all actions were correct but the outcome is not what was expected.

For example, in ballroom dancing a couple works together. If one of the partners missteps it will throw off the entire dance; similarly if one adds an unexpected movement or step, it again throws off the whole dance. An unexpected outcome would be something on the dance floor which trips up the partners even though they were making the proper movements. In each case it is observable that something went amiss, and there needs to be corrective action to salvage the dance.

In error proofing a process, one needs a means of observing and detecting anomalies which can then be corrected quickly to avoid an adverse outcome. Late detection means a greater negative impact and greater corrective actions needed. It is best when creating steps for detection to insert multiple checkpoints, to catch the error as close to the source as possible.

Click on the images below for examples.

Industry/Business
Medical

 

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Patient safety module series used with permission from Duke University
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