Comments on: Error Proofing Handwashing? http://www.leanblog.org/2009/02/error-proofing-handwashing/ Mark Graban's leanblog.org - Lean Healthcare, Lean Thinking, Lean Manufacturing, Toyota Production System Thu, 09 Feb 2012 22:59:58 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Richard Chapman http://www.leanblog.org/2009/02/error-proofing-handwashing/#comment-21192 Richard Chapman Fri, 03 Jun 2011 02:44:00 +0000 http://leanblog.bigbigdesign.net/2009/02/error-proofing-handwashing/#comment-21192 Even that I don't buy. Lots of hospital TV dramas have people dying on the table because you didn't resuss within seconds, but in reality I would rather have docs and nurses with clean hands, no matter what. We don't know if 10 other people didn't die of drug resistant infections because we washed our hands rather than rush straight to our hypothetical patient who was beeping away on the monitor somewhere. I still think the problem needs to be relooked at at even more fundamental level. If the door handle from the washroom was literally immersed in a small basin of sterilizing fluid and couldn't be opened without immersing hands in it, that provides that literal connection between a 'desired' function ie opening the door, and an 'undesired' function of washing hands. It would also be better to get heroism out of healthcare. You might be a heroic young doctor who's swotted up all the textbooks and paid the big dollars, but the microorganisms don't care and are living on your skin just as much as on the homeless guy sitting in the emergency room. Even that I don’t buy. Lots of hospital TV dramas have people dying on the table because you didn’t resuss within seconds, but in reality I would rather have docs and nurses with clean hands, no matter what.

We don’t know if 10 other people didn’t die of drug resistant infections because we washed our hands rather than rush straight to our hypothetical patient who was beeping away on the monitor somewhere.

I still think the problem needs to be relooked at at even more fundamental level. If the door handle from the washroom was literally immersed in a small basin of sterilizing fluid and couldn’t be opened without immersing hands in it, that provides that literal connection between a ‘desired’ function ie opening the door, and an ‘undesired’ function of washing hands.

It would also be better to get heroism out of healthcare. You might be a heroic young doctor who’s swotted up all the textbooks and paid the big dollars, but the microorganisms don’t care and are living on your skin just as much as on the homeless guy sitting in the emergency room.

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]]> By: Anonymous http://www.leanblog.org/2009/02/error-proofing-handwashing/#comment-4590 Anonymous Mon, 23 Feb 2009 15:56:00 +0000 http://leanblog.bigbigdesign.net/2009/02/error-proofing-handwashing/#comment-4590 Is there any risk that a member of the hospital staff would not get to a patient fast enough because of this device? Would there need to be an override? Would the nurse/doctor arriving to administer cpr to a patient in cardiac arrest have to rub in the gel or foam before attempting to save the patients life? Just a thought. Is there any risk that a member of the hospital staff would not get to a patient fast enough because of this device? Would there need to be an override? Would the nurse/doctor arriving to administer cpr to a patient in cardiac arrest have to rub in the gel or foam before attempting to save the patients life? Just a thought.

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]]> By: rearden215 http://www.leanblog.org/2009/02/error-proofing-handwashing/#comment-4579 rearden215 Fri, 20 Feb 2009 13:41:00 +0000 http://leanblog.bigbigdesign.net/2009/02/error-proofing-handwashing/#comment-4579 Mark, I was referring to the tollgate-styled dispenser which blocks access until one places a hand under the dispenser.<br/><br/>This seems like yet another example of the dumbing down or 'sailor proofing' of a task which takes away one's sense of personal accomplishment through accountability. And, yes, 100% compliance is too dependent upon humans to be realistic.<br/><br/>If we are too overzealous in sailor-proofing we risk becoming a dystopia.<br/><br/>I would hope that healthcare folks would be diligent in this matter. Mark, I was referring to the tollgate-styled dispenser which blocks access until one places a hand under the dispenser.

This seems like yet another example of the dumbing down or ‘sailor proofing’ of a task which takes away one’s sense of personal accomplishment through accountability. And, yes, 100% compliance is too dependent upon humans to be realistic.

If we are too overzealous in sailor-proofing we risk becoming a dystopia.

I would hope that healthcare folks would be diligent in this matter.

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]]> By: Mark Graban http://www.leanblog.org/2009/02/error-proofing-handwashing/#comment-4578 Mark Graban Fri, 20 Feb 2009 13:18:00 +0000 http://leanblog.bigbigdesign.net/2009/02/error-proofing-handwashing/#comment-4578 Rearden - how does this error proofing treat people as stupid? They aren't like Frederick Taylor, calling workers stupid and ox-like.<br/><br/>People in hospitals are very smart... yet hand hygiene practices aren't followed 100%. It's not a matter of smart or dumb... it's about making it hard for smart people to make mistakes. People forget... we're not perfect (plus management isn't paying close attention to the hygiene issue typically). A device like this helps, does it not? Rearden – how does this error proofing treat people as stupid? They aren’t like Frederick Taylor, calling workers stupid and ox-like.

People in hospitals are very smart… yet hand hygiene practices aren’t followed 100%. It’s not a matter of smart or dumb… it’s about making it hard for smart people to make mistakes. People forget… we’re not perfect (plus management isn’t paying close attention to the hygiene issue typically). A device like this helps, does it not?

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]]> By: rearden215 http://www.leanblog.org/2009/02/error-proofing-handwashing/#comment-4576 rearden215 Thu, 19 Feb 2009 23:37:00 +0000 http://leanblog.bigbigdesign.net/2009/02/error-proofing-handwashing/#comment-4576 This seems like something straight out of 'Shockwave Rider'.<br/><br/>Although the intention is good, the implementation treats us like we are not too smart. This seems like something straight out of ‘Shockwave Rider’.

Although the intention is good, the implementation treats us like we are not too smart.

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]]> By: Anonymous http://www.leanblog.org/2009/02/error-proofing-handwashing/#comment-4574 Anonymous Wed, 18 Feb 2009 17:15:00 +0000 http://leanblog.bigbigdesign.net/2009/02/error-proofing-handwashing/#comment-4574 As a prototype I think it is a good idea. I do have some questions about the room enter-exit sensor. <br/><br/>My big concern of hand washing in hospitals is visiting families. If the first person washes their hands can the rest of the visitors pile in the room. I know limiting the number of visitors in a room at once is common practice however I see this rule broken very often for the very sick. As a prototype I think it is a good idea. I do have some questions about the room enter-exit sensor.

My big concern of hand washing in hospitals is visiting families. If the first person washes their hands can the rest of the visitors pile in the room. I know limiting the number of visitors in a room at once is common practice however I see this rule broken very often for the very sick.

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