Operationalizing Perceived Safety through Poka-Yoke Systems: A Mixed-Methods Analysis of Error-Proofing Mechanisms on Patient Experience Metrics in Tertiary Care Hospitals


Poka-yoke, a Japanese term meaning "mistake-proofing," originated in manufacturing to eliminate errors through process design. In healthcare, where human errors can lead to life-threatening consequences, its principles are increasingly vital. This methodology focuses on embedding error-proofing mechanisms into systems to prevent mistakes before they occur or detect them immediately. Applications range from standardized surgical checklists and automated medication dispensing systems to color-coded equipment and electronic health record alerts. By reducing reliance on human vigilance, poka-yoke addresses systemic failures such as misdiagnoses, dosage inaccuracies, and procedural oversights. Current research explores its potential to enhance patient safety, streamline workflows, and mitigate costs associated with preventable errors. As healthcare systems grapple with rising complexity and workforce burnout, poka-yoke offers a proactive framework to transform error-prone processes into fail-safe operations. Its integration into healthcare innovation underscores a paradigm shift toward prevention-oriented, patient-centred care models.



Application for poka-yoke Research


Poka-yoke (Japanese for "mistake-proofing") is a strategy to design systems or processes that prevent errors before they occur or detect mistakes immediately to minimize harm. Think of it as "safety nets" built into everyday tasks. An electronic health record (EHR) alerting a nurse about a patient’s drug allergy before administering medication and managing that issue/ problem will reduce the medical error cases in hospitals.



Healthcare errors (e.g., misdiagnoses, wrong dosages) are a leading cause of preventable harm. Poka-yoke tackles this by Checklists for surgeries or medication administration and for Color-coded equipment (e.g., red tags for emergency tools). Barcode scanners to match patients with their medications.

 


Current Trends Driving Adoption of AI and Smart Devices


This is another area of interest for the research Tools like IBM Watson analyse patient data to flag risks (e.g., sepsis) in real time. Automatically stop dispensing drugs if the dosage exceeds safe limits.


Telehealth Expansion


Remote care introduces new risks (e.g., miscommunication). Poka-yoke solutions include Automated reminders for virtual follow-ups. It also helps in EHR templates that guide clinicians to ask critical questions during telehealth visits.


Cost and Regulatory Pressures


Hospitals face penalties for preventable errors (e.g., under Medicare’s "No Pay for Errors" policy). Poka-yoke reduces costly mistakes like hospital-acquired infections through standardized sterilization protocols.


Patient Empowerment


Apps with built-in error checks (e.g., diabetes management tools that warn about unsafe blood sugar levels). Simplified medication packaging with clear labels to prevent confusion.

 


Scope of Uses of Poka Yoke in Healthcare


Sensors in surgical instruments that detect misplaced tools. Gamified training modules to reinforce error-proof habits among staff. Low-cost poka-yoke solutions (e.g., color-coded vaccine vials for use in resource-limited settings).


By embedding mistake-proofing into healthcare’s DNA, we shift from fixing errors to designing systems where errors cannot exist. This aligns with today’s focus on precision medicine, value-based care, and patient safety as a human right.

 


Conclusions


Poka-yoke, or mistake-proofing, transforms healthcare by pre-emptively addressing errors through system design rather than reliance on human perfection. Originating in manufacturing, its healthcare applications—such as surgical checklists, smart medication dispensers, and AI-driven alerts—reduce risks like misdiagnoses and dosage errors. Current trends, including telehealth expansion and IoT integration, amplify its relevance by embedding safeguards into digital workflows and remote care. Regulatory pressures (e.g., penalties for preventable errors) and cost efficiency further drive adoption. By prioritizing prevention over correction, poka-yoke aligns with modern healthcare’s goals: precision medicine, patient safety, and value-based care. Ultimately, it fosters resilient systems where errors are structurally impossible, enhancing outcomes while curbing costs—a critical shift as healthcare complexity grows globally.

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