title: [Understanding mistake-proofing].
abstract: The mistake-proofing concept often refers to physical devices that prevent actors from making a wrong action. In anaesthesiology, one immediately thinks to specific design of outlets for medical gases. More generally, the principle of mistake-proofing is to avoid an error, by placing knowledge in the world rather than knowledge in the head. As it often happens in risk management, healthcare has received information transfers from the industry. Computer is changing the concept of mistake-proofing, initially based on physical design, such as aerospace and automotive industry. The mistake-proofing concept may be applied to prevention, detection, and mitigation of errors. The forcing functions are a specific part of mistake-proofing: they prevent a wrong action or they force a virtuous one. Grout proposes a little shortcut to identify mistake-proofing devices: "If it is not possible to picture it in action, it is probably not a mistake-proofing device".
authors.affiliation: Service d'anesthésie-réanimation, hôpital d'Instruction des Armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France. gsmopex@yahoo.fr
authors.forename: G
authors.initials: G
authors.lastname: de Saint Maurice
authors.forename: N
authors.initials: N
authors.lastname: Giraud
authors.forename: S
authors.initials: S
authors.lastname: Ausset
authors.forename: Y
authors.initials: Y
authors.lastname: Auroy
authors.forename: B
authors.initials: B
authors.lastname: Lenoir
authors.forename: R
authors.initials: R
authors.lastname: Amalberti
mesh_terms: D000776:Anesthesiology / Q000592:standards*; D018685:Anesthetics, Inhalation / Q000009:adverse effects; D003201:Computers; D006801:Humans; D007221:Industry / Q000592:standards; D019300:Medical Errors / Q000517:prevention & control*; D058996:Quality Improvement; D011787:Quality of Health Care; D012308:Risk Management; D012449:Safety
chemical_list: D018685:Anesthetics, Inhalation