Grout J R
Berry College, Campbell School of Business, Mount Berry, GA 30149-5024, USA.
Qual Saf Health Care. 2006 Dec;15 Suppl 1(Suppl 1):i44-9. doi: 10.1136/qshc.2005.016030.
Mistake proofing uses changes in the physical design of processes to reduce human error. It can be used to change designs in ways that prevent errors from occurring, to detect errors after they occur but before harm occurs, to allow processes to fail safely, or to alter the work environment to reduce the chance of errors. Effective mistake proofing design changes should initially be effective in reducing harm, be inexpensive, and easily implemented. Over time these design changes should make life easier and speed up the process. Ideally, the design changes should increase patients' and visitors' understanding of the process. These designs should themselves be mistake proofed and follow the good design practices of other disciplines.
防错通过改变流程的物理设计来减少人为错误。它可用于以防止错误发生的方式改变设计,在错误发生后但在造成伤害之前检测错误,使流程安全失效,或改变工作环境以降低出错几率。有效的防错设计变更最初应能有效减少伤害、成本低廉且易于实施。随着时间推移,这些设计变更应使生活更轻松并加快流程。理想情况下,设计变更应增进患者和访客对流程的理解。这些设计本身也应具备防错功能,并遵循其他学科的良好设计规范。