Order Sets: A Poka-Yoke For Clinical Decisions

Poka (unintended mistake) Yoke (avoid) is the Japanese equivalent for “error proofing.” This Lean Manufacturing strategy is more relevant than ever in healthcare today. Why?

FIRST, DO NO HARM
The Supreme Court of India recently ordered one of the largest compensations so far in the country to a girl who lost her vision at birth in a case of medical negligence. The girl, who is now 18 years old, was born prematurely at a government hospital but was discharged from the hospital without a retinopathy test, a must for prematurely born babies. By the time the family discovered the lapse, the girl had lost her vision.

Fentanyl is a potent opioid medication used as part of anesthesia. A hospital pharmacist received an order for a ‘fentanyl drip 5,200 mcg per hour,’ which a nurse had just transcribed after accepting a telephone order. The pharmacist called the nurse to clarify the dose. The nurse confirmed that, although the dose was large, she had “read back” the order to the anesthesiologist several times to make sure she had heard the dose correctly. The pharmacist called the anesthesiologist himself, only to find that the intended order was for a fentanyl drip 50 to 100 mcg per hour.

The frequency of preventable medical errors resulting in patient injury and death is staggering. It is estimated that for every 100 hospitalisations, approximately 14 adverse events occur, translating to roughly 43 million avoidable patient injuries worldwide each year. In terms of quality of life for those inadvertently hurt: the loss of nearly 23 million years of healthy life3. And avoidable medical errors don’t just injure patients. Between 200,000 and 400,000 patients die every year in the United States as a result of preventable medical errors,4 making avoidable hospital deaths the number three killer of American adults.

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