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Error Proofing:
Use Differentiation

Errors can occur when we are dealing with things that look similar. We may copy a wrong number or grab a wrong part because of their similarity or close proximity to other numbers or parts. Errors can also occur when actions are similar. We may end up in the wrong place or use a piece of equipment in the wrong way because the right directions or procedures are similar to others we might have used in a different situation. For example, we wind up driving to work on Sunday morning instead of to the bakery. Our minds at times will associate the required things and actions with similar but inappropriate ones. Familiarity that results from experience can actually increase the chance of committing errors of association. To reduce errors, steps should be taken to break patterns. This can be done in such ways as color coding, sizing, using different symbols, or by separating similar things.




Examples of Tests of this Change

One organization that stocked two concentrations of morphine sulfate in identical cartridges asked the pharmacy to label the higher-concentration cartridge with bright orange tape.

One organization elected to store two concentrations of intravenous (IV) heparin on separate shelves in the medication room.

One hospital created a chart comparing generic and trade names of narcotics, and attached the chart to the narcotics box.


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