Hospital Lean: Error Proofing


See this link: Stay safe in the hospital

For some people, this is “Everyday Lean” unfortunately. Some great tips here if you, or someone you love, is going into the hospital, tips for preventing mistakes.

There are plenty of lean principles or opportunities for lean at play here, but I was thinking of one, in particular:

“Busy staffers may mistake micrograms for milligrams or mistake one patient for another.”

When typed out, you can tell the abbreviations for micrograms and milligrams apart.


But, when written out by hurried doctors, these easily can get confused. Here is my attempt to write them out. That's “micrograms” on the left.


So, what do you do? We're not yet in the era of the “paperless hospital.” In theory, these types of things should never be handwritten. But, today, they are in most (or many) hospitals. You could tell the doctors and everyone involved to “be careful.” But, that's not very effective error proofing.

Some hospitals are making a systemic process change that they hope will prevent this error. They are banning the typical abbreviation for micrograms. They want everyone to use “mcg” for micrograms and “mg” for milligrams.


Much better than telling everyone to “be careful.” You just have to get everyone to follow this new “standard work.” Old habits will be hard to break, but lives are at stake.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.



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