Getting Started Purpose of This Book What This Book Is Based On Two Ways to Use This Book How to Get the Most Out of Your Reading Become Familiar with This Book as a Whole Become Familiar with Each Chapter Using a Reading Strategy Using the Margin Assists Overview of the Contents Chapter 1: Getting Started Chapter 2: The Production Processes and Operations of Healthcare Chapter 3: Introduction to Mistake Proofing Chapter 4: Basic Elements of the Mistake-Proofing System Chapter 5: Using Poka-Yoke Systems Chapter 6: Examples of Poka-Yoke Applications Chapter 7: Reflections and Conclusions The Production Processes and Operations of Healthcare The Industrial Origins of Lean Healthcare Production, Process, and Operation Principles of Lean Healthcare Management Standard Work Autonomation Flow Production Plan-Do-Check-Act Socratic Method Summary Reflections Introduction to Mistake Proofing What Is Mistake Proofing? Why Focus on Zero Defects? How Mistake Proofing Makes Work Easier What Causes Defects? Communication Errors Cognitive Errors Red-Flag Conditions Controlling Conditions So Defects Do Not Happen The Traditional Quality Improvement Cycle Integrating PDCA in the Mistake-Proofing Approach Summary Reflections Basic Elements of the Mistake-Proofing System Quality at the Source The Four Elements of Mistake Proofing Three Approaches to Inspection Judgment Inspections Reveal Defects Informative Inspections Reduce Defects Statistical Quality Control Successive Checks Self-Checks Source Inspection Keeps Errors from Becoming Defects 100 Percent Inspection Catches All Errors A Short Feedback Loop Means Quicker Action on Problems Poka-Yoke Systems Catch Errors We Might Have Missed Summary Reflections Using Poka-Yoke Systems About Poka-Yoke Systems Poka-Yoke Systems in Source Inspection and in Informative Inspection (Self-Checks and Successive Checks) How Poka-Yoke Systems Regulate the Process Types of Poka-Yoke Systems Method Poka-Yokes Checklists in Healthcare Using Checklists Effectively Stop the Line--Stop the Process Physical Poka-Yokes Contact or Identification Techniques Fixed-Value or Number Techniques Motion-Step or Sequence Techniques Poka-Yoke Sensors Devices that Link to Poka-Yoke Sensors Summary Reflections Examples of Poka-Yoke Applications Learning from Examples of Poka-Yoke Applications Method Poka-Yoke Examples Thoracic Surgery Checklist Red Event Safety Alert, Incident Command Checklist Chart Preparation Checklist Rounding Checklist Clinician Previsit Checklist Electronic Health Systems Contact or Identification Poka-Yoke Examples Integrated Color-Coding Systems Other Color-Coding Poka-Yokes Wristbands with Bar Codes or Radio-Frequency Identification Tags Tactile Signals on Wrong Buttons Throat Pack Identification Shrink-Wrapping on Dangerous Medications Fixed-Value or Number Poka-Yoke Examples Surgical Sponge-Counting Systems Automatically Timed Processes Automated External Defibrillator Bed Angle Visual Aid Pulse Oximeter Motion-Step or Sequence Poka-Yoke Examples Oral Care Pegboard Glucose Test Reminder Hand Hygiene Monitoring Systems Sheathed Needles Summary Reflections Reflections and Conclusions Reflecting on What You Have Learned Applying What You Have Learned Possibilities for Applying What You Have Learned Your Personal Action Plan Opportunities for Further Learning Conclump; Chapter 5: Using Poka-Yoke Systems Chapter 6: Examples of Poka-Yoke Applications Chapter 7: Reflections and Conclusions The Production Processes and Operations of Healthcare The Industrial Origins of Lean Healthcare Production, Process, and Operation Principles of Lean Healthcare Management Standard Work Autonomation Flow Production Plan-Do-Check-Act Socratic Method Summary Reflections Introduction to Mistake Proofing What Is Mistake Proofing? Why Focus on Zero Defects? How Mistake Proofing Makes Work Easier What Causes Defects? Communication Errors Cognitive Errors Red-Flag Conditions Controlling Conditions So Defects Do Not Happen The Traditional Quality Improvement Cycle Integrating PDCA in the Mistake-Proofing Approach Summary Reflections Basic Elements of the Mistake-Proofing System Quality at the Source The Four Elements of Mistake Proofing Three Approaches to Inspection Judgment Inspections Reveal Defects Informative Inspections Reduce Defects Statistical Quality Control Successive Checks Self-Checks Source Inspection Keeps Errors from Becoming Defects 100 Percent Inspection Catches All Errors A Short Feedback Loop Means Quicker Action on Problems Poka-Yoke Systems Catch Errors We Might Have Missed Summary Reflections Using Poka-Yoke Systems About Poka-Yoke Systems Poka-Yoke Systems in Source Inspection and in Informative Inspection (Self-Checks and Successive Checks) How Poka-Yoke Systems Regulate the Process Types of Poka-Yoke Systems Method Poka-Yokes Checklists in Healthcare Using Checklists Effectively Stop the Line--Stop the Process Physical Poka-Yokes Contact or Identification Techniques Fixed-Value or Number Techniques Motion-Step or Sequence Techniques Poka-Yoke Sensors Devices that Link to Poka-Yoke Sensors Summary Reflections Examples of Poka-Yoke Applications Learning from Examples of Poka-Yoke Applications Method Poka-Yoke Examples Thoracic Surgery Checklist Red Event Safety Alert, Incident Command Checklist Chart Preparation Checklist Rounding Checklist Clinician Previsit Checklist Electronic Health Systems Contact or Identification Poka-Yoke Examples Integrated Color-Coding Systems Other Color-Coding Poka-Yokes Wristbands with Bar Codes or Radio-Frequency Identification Tags Tactile Signals on Wrong Buttons Throat Pack Identification Shrink-Wrapping on Dangerous Medications Fixed-Value or Number Poka-Yoke Examples Surgical Sponge-Counting Systems Automatically Timed Processes Automated External Defibrillator Bed Angle Visual Aid Pulse Oximeter Motion-Step or Sequence Poka-Yoke Examples Oral Care Pegboard Glucose Test Reminder Hand Hygiene Monitoring Systems Sheathed Needles Summary Reflections Reflections and Conclusions Reflecting on What You Have Learned Applying What You Have Learned Possibilities for Applying What You Have Learned Your Personal Action Plan Opportunities for Further.