IOM Key Safety-Design Concepts and Principles for the Design of Safety Systems in Health Care Organizations

Key safety-design concepts
    Make things visible so that the user can determine what actions are possible at any momentDefibrillator dials should be clearly visible to the user on the front display
    Simplify the structure of tasks to minimize the load on working memory, planning, or problem-solvingConcentrations for continuous-drip medications should be limited and standardized on the hospital formulary
    Use affordances—characteristics of equipment or workspace that communicate how it is to be usedOral syringes are designed to administer oral medications and cannot be connected to an intravenous line because of the bulbous tip, except with exceptional force
    Use natural mappings—relationships between a control and its movementTurning a medical instrument knob to the right should make the related dial needle point further to the right
    Use constraints or “forcing functions” that guide the user to the next appropriate action or decisionCPOE systems can be programmed so that they do not allow the prescriber to proceed without the patient's weight and allergy history
    Assume that errors will occur and design and plan for recovery by making it easy to reverse operations and hard to perform nonreversible onesMachine-readable patient-identification systems, such as bar-coding, act as a final check to prevent harm in situations in which another patient's medication has been mistakenly retrieved to administer to the wrong patient
    If applying the earlier strategies does not achieve the desired results, standardize actions, outcomes, layouts, and displaysChemotherapy protocols and order sets should be standardized and preprinted or programmed into CPOE systems
Principles for the design of safety systems in health care organizations
    Provide leadershipMake patient safety a priority corporate objective
Make patient safety everyone's responsibility
Make clear assignments for and expectation of safety oversight
Provide human and financial resources for error analysis and systems redesign
Develop effective mechanisms for identifying and dealing with unsafe practitioners
    Respect human limits in process designDesign jobs for safety
Avoid reliance on memory
Use constraints and forcing functions
Avoid reliance on vigilance
Simplify key processes
Standardize work processes
    Promote effective team functioningTrain in teams those who are expected to work in teams
Include the patient (and/or family) in safety design and the process of care
    Anticipate the unexpectedAdopt a proactive approach: examine processes of care for threats to safety and redesign them before accidents occur
Design for recovery
Improve access to accurate, timely information
    Create a learning environmentUse simulations whenever possible
Encourage reporting of errors and hazardous conditions
Ensure no reprisals for reporting of errors
Develop a working culture in which communication flows freely regardless of authority gradient
Implement mechanisms of feedback and learning from error
  • Data source: Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.