To err is human, but human errors in medicine can be dangerous or even deadly. Using a Japanese technique called poka-yoke (pronounced “po-ka yo-kay”) or mistake-proofing, medical professionals can make human mistakes much less harmful, according to Marriott School alum John Grout, dean of the Campbell School of Business at Berry College.
Even with great employees and active training, mistakes are inevitable, Grout says. Poka-yoke recognizes the inherent possibility of errors and works to make the results less disastrous. It often achieves those results by creating failures that stop the process before disaster strikes.
“Suppose you were riding in an elevator,” Grout says. “If it stopped between floors, you would call that a failure. But it’s a failure that’s preferable to falling to your death.”
The elevator brake is an early example of mistake-proofing. Elisha Otis, inventor of the elevator brake, had anticipated the possibility of the rope breaking and changed the outcome. The process has still failed because the passenger hasn’t arrived at the chosen floor, but the consequences are much less harmful.
Similarly, the consequences of human error in hospitals and care facilities can be changed to prevent harm. Much of Grout’s recent work deals with helping medical professionals apply mistake-proofing techniques. A federal agency is distributing his book on mistake-proofing health care processes to hospitals around the country. The book gives examples of medical mistake-proofing in action and teaches relevant mistake-proofing approaches.
For example, a simple thermostatic water shutoff valve can prevent attendants from drawing bathwater if the water temperature is too high. This creates a benign failure—the inability to start a bath—instead of a much more dangerous failure that could potentially result in a scalded patient. Another example is the practice of marking the correct location for a surgery before a patient is brought in. This simple step can prevent the traumatic problem of operating on the wrong side or in the wrong location.
“These problems can injure or kill patients,” Grout says. “I’m hoping this book will be a catalyst to help hospitals address failures in a whole new way.”
In July, Grout became dean of the Campbell School of Business at Berry College, which is located on more than 26,000 acres of forestland near Rome, Georgia. He has been a faculty member at the school since 1997. Grout earned his BS in business operations and systems analysis from BYU in 1984 and a doctorate from Penn State University. He recently received the Shingo Prize, named after the pioneer of poka-yoke, for his work with mistake-proofing.
In his limited spare time, Grout enjoys woodcarving. His favorite carving subjects are Jonah and the whale. He and his wife, Susan, have four children.
