QUERI – Quality Enhancement Research Initiative

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Quality Improvement Methods

35. Poka-Yoke Technique

a. Definition: useful good way to be sure that will be done correctly, is to organize it so that there is only one way to do it or it is obvious what the proper way is to do it. Poka-Yoke is a Japanese term for "error proofing" or "mistake proofing." It is used to prevent errors by the design of tasks or workspace. Errors in healthcare are particularly serious so that methods such as this are important. Research which results in a change to an existing procedure might use it to assure work is done the new way and not the old one.

Error proofing may mean that a work step can only be done one way because alternatives are physically impossible. This can be plugs that can be connected only one way or a machine that can only be started if switches are set a certain way. Information systems can be designed so that only acceptable combinations can be selected.

b. Literature:

  • Shingo, Shigeo. Zero quality control: Source inspection and the poka-yoke system. Productivity Pr, 1986.
  • Grout, J. R. "Mistake proofing: changing designs to reduce error." Quality and Safety in Health Care 15.suppl 1 (2006): i44-i49.

c. Example: Store tools in space with an outline of the tool so that it is obvious when a tool is gone or stored incorrectly.

 Store tools in space with an outline of the tool so that it is obvious when a tool is gone or stored incorrectly.

In the picture below the lower set of plugs is designed so as to assure the proper match of the positive and negative wires. It is impossible to connect the lower pair improperly.

lower set of plugs is designed so as to assure the proper match of the positive and negative wires. It is impossible to connect the lower pair improperly

Also, hospitals use colors, such as colors on patient wristbands or colored strips on the floor to direct patients to the correct area.

d. Steps: This concept is to identify actions that could produce an error and then design ways to prevent an error by physical design or signals that alert the user to an obvious error.

1) Identify the need or situation where an error is possible

2) Identify ways error could be made

3) Implement changes so that only correct actions are possible

4) Monitor use and revise if necessary