ABSTRACT
Ensuring quality at the source, through detecting and preventing errors, is one of the pillars of the Toyota Production System. Preventing that same error from occurring in our own hospital is good for the patients, good for the employees, and good for the hospital. When managers blame individuals for errors, there is an underlying–but unrealistic–assumption that errors could be prevented if people would just be more careful. Errors are often viewed as the result of careless or inattentive employees. The error proofing is more effective than if we only relied on signs or warning labels that said "Be careful; do not use diesel fuel in this vehicle." Error proofing has a Japanese equivalent term, poka yoke, which is sometimes used in Lean circles. One technological method for reducing handwriting errors, for pharmacy prescriptions, laboratory test orders, or other communications, is electronic systems, such as computerized physician order entry or other electronic medical record systems.
