Table 1 Examples of what constitutes mistake proofing using the definition in this paper.

Mistake proofing

• Make the colors of the tube and the point where the tube should be connected the same

• Change the shapes of the tube and the point where the tube should be connected so that the wrong tube cannot be connected

• Use infusion pumps that regulate the flow intravenous fluids

• Change colors of the tubes by medication

• Standardize the valves in the whole hospital

• Put in an automatic timer

• Use a partitioned cart which can contain only a certain number of medications

• Differentiate labels among concentrations

Not mistake proofing

• Set up a brief meeting between the physician and clinical and clerical support staff (known as a “huddle”) to review the schedule and identify ways to make the day flow better and do contingency planning for unexpected demand

• Note on the encounter sheet that the patient needs to return in 4 weeks for a 30 minute appointment

• Require two nurses to independently check the label on a unit of blood against the patient's identification band

• Emphasize to callers that calls will be returned “at the end of office hours”

• Forward patient calls to an automated direction line that the hospital operates as soon as they have finished booking the examination

• Make sure that examination rooms are stocked and the supplies and equipment are arranged in a standard way

• Require a chart review, normally done the day before or the morning of the visit, to determine whether all appropriate documentation is in the chart and ready for the physician

• Pharmacy intervention for non‐standard concentrations

Examples come from the error proofing database in the paper by Godfrey et al.⁶