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Medical Tragedy Can Be Easily Prevented by Error Proofing

Ford’s “Can’t Rather Than Don’t” principle is applicable to any industry

William A. Levinson
Tue, 07/19/2011 - 11:11
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Dr. Gary Brandeland’s article, “The Day Joy Died,” which appeared in the Oct. 20, 2006, edition of Modern Medicine, underscores the primitive nature of quality thinking—and more specifically, safety thinking—in hospitals. Although I’m not going to give formal engineering advice about medical devices I’ve not actually seen, it’s clear from the narrative that the death of this patient along with serious injury to her unborn child could have easily been prevented by rudimentary quality and safety thinking. I refer specifically to Henry Ford’s “Can’t Rather Than Don’t” safety principle, which is also useful to any organization working with OSHAS 18001.

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“Can’t Rather Than Don’t” refers to a kind of error-proofing that prevents rather than warns. For example, instead of warning signs and instructions that tell workers, “Don’t put your hand in the mechanical press while it closes,” the press itself is designed so the worker can’t put his hand into it when it closes.

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Comments

Submitted by Ryan E. Day on Wed, 07/20/2011 - 15:42

Your piece clearly outlines

Your piece clearly outlines an all-too-common practice and mindset of don't change anything until forced to by lawsuit or death.  I've been witness to this in industry as well.  It leaves me with palms up and head shaking...why? Even tractors have built in fail safes. I cannot fathom why healthcare practitioners would deem it unnecassary. Sometimes Bill, I wish your writing was just a little less clear and well thought out 'cause this one makes me feel pretty low.

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Submitted by mgraban on Fri, 07/22/2011 - 14:45

In reply to Your piece clearly outlines by Ryan E. Day

Leadership

The qualty problems in healthcare are not technical or scientific issues... they are leadership issues, namely a lack of serious leadership and effort around error proofing and quality improvement.

Healthcare still relies far too often on lecturing people to "be careful" and individuals are punished when things go wrong. 

We know how to fix these problems, but people just don't.

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