I've talked a little about using lean to prevent medical mistakes. This mistake, someone using hydraulic fluid to clean surgical instruments, is mind boggling. It mekes you wonder if the bottle/can of hydraulic fluid was in a bottle that looked visually very similar to the cleaning solution bottle/can? Like we need more worries about a hospital visit.
Off the top of my head, it seems like they could either store/repackage cleaning solutions in visually obvious bottles even if it's not the OEM bottle (“blue bottles” are for cleaning solutions) or make sure non-cleaning solutions are not stored anywhere near cleaning solutions. Simple visual management and 5S tools could be used to prevent this, maybe combined with better standard work and training.
Either way, it seems like it would help to have a network of hospitals to communicate errors like this — once an error like this happens, it would be nice to see ALL hospitals take proactive corrective actions to prevent this same failure mode from ever happening again.
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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus. His latest book has been released as an "in-progress" book, titled Measures of Success.
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