Summary

The six basic principles of mistake proofing in health care are elimination, replacement, facilitation, detection, mitigation, and patient involvement. These methods enable us to decrease the likelihood that errors will occur, and to reduce the impact when they do. Though these are six discrete strategies for protecting against error, the best means of creating an error-proof system is layering different prevention methods together. If you are able to replace a step with an automated process, you should also ensure that there are detection and mitigation tools in place in case the automated process goes awry.

Clinical guidelines based on evidence are an important strategy for simplifying and standardizing care to reduce the chance of errors. Adherence to guidelines reduces underuse and overuse problems, and by limiting practice variation also reduces the risk of other errors.

Error-proofing is the goal. A healthy appreciation of the fact that complex systems will fail is essential to help us both identify potential failing points and create safety nets for those points of failure.