Preface

Avoiding 'Oops!' It is really funny to think that a nurse is a keeper of all Oops in the medical profession. Yet, the Institute of Medicine report on medical errors stresses systematic changes, and experts agree that individual nurses play key roles in preventing mistakes. For example, most of us outside the medical profession think and believe that the onus of responsibility often ends with the nurse. We believe that nurses, generally speaking, are supposed to track the physicians' errors. They're supposed to catch the pharmacists' errors. They're supposed to catch their own errors. They're supposed to catch the patients ' errors. So they're in a real vulnerable position.

But nurses are not the only ones. Operators in manufacturing plants and, in fact, workers everywhere are thought of being perfect and if they ever make mistakes they should be reprimanded. We all have forgotten that variation exists and as long as it is possible for the system to generate variation, variation will exist regardless of who is doing the task.

Thus, nurses, operators, and workers in general can reduce their vulnerability for blame by heeding the following advice for creating a safer environment:

• Don't cut corners . Everything is ASAP today. It seems that everyone is short of staff, everyone wants to do it faster, and the end result is to accommodate everyone with problems by cutting corners. When we do that, the propensity for errors rises dramatically. Obviously, the advice to everyone dealing with a subtle innuendo to cut corners is that the individual presented with the alternative of cutting corners at the expense of quality issue is to be assertive in demanding enough time to do the assigned task correctly.

• Speak up . The ethical code for any one in any organization requires that they report unsafe practices. It you don't have the time, supplies , or whatever else to do your job properly, you need to report the situation to your supervisor immediately. If you don't know, ask. Check it out with a colleague ”it is not a sign of weakness. Rather, you could be saving someone's life.

• Keep your skills up-to-date . Knowing the right way to do something goes a long way toward avoiding mistakes. It is imperative to keep your learning current and ask management to provide the appropriate skills for your particular situation(s).

• Join or create an employee-safety committee . Employees generally are the primary advocates for safety and quality and should have a voice in any safety-quality forum.

• Include error reduction in the strategic plan of your unit/department . Employee safety shouldn't be an afterthought following a mistake. The appropriate personnel should regularly look at error data, analyze it, and develop plans to prevent the errors from recurring.

• Raise the issue of employee safety during any discussion of planned change . Change happens constantly, but the dynamic environment it creates increases the potential for mistakes. Employee safety ought to be a litmus test that gets raised in almost every meeting, no matter what the discussion. How will employee safety be impacted by what we're talking about?

• Change your mind-set . All of us are thinking of how to do a particular task because we have been conditioned to think in a task-oriented behavior. If, on the other hand, we are committed to a mistake-proof environment we should start thinking in terms of "administering tasks ," which of course is a higher cognitive thought process. Continually ask yourself: Why is this task being done this particular way? Is this right? Is it appropriate? Can it be done in a different way? If so, how? What would be the ramifications of the change? How should it be done?

• Create a climate of support . Employees have to be supportive of each other when an error is made. Managers should thank staff for reporting errors and not record incidents in personnel files. Rather, they should look at systematic changes to avoid errors in the future. Unless you remove the stigma of the error and evaluate what went wrong, it will continually repeat.

• Focus on the process . It is easy to say, but very difficult to implement and consistently practice for many reasons. Hopefully, in this volume we will examine some issues and concerns that everyone should be aware of in his or her own process for optimum results.

Our focus, then, in this volume is to address the following:

• Chapter 1 ”what a process is and how we can evaluate that process for optimum results

• Chapter 2 ”the basic problem-solving techniques

• Chapter 3 ”summarizing data

• Chapter 4 ”descriptive statistics

• Chapter 5 ”normal distribution

• Chapter 6 ”control chart theory

• Chapter 7 ”preparing for control charts

• Chapter 8 ”variable charts

• Chapter 9 ”attribute charts

• Chapter 10 ”other special charts

• Chapter 11 ”control chart signals

• Chapter 12 ”capability

• Chapter 13 ”short-run SPC

• Chapter 14 ”distributions and stability

• Chapter 15 ”measurement system analysis

• Chapter 16 ”machine acceptance

• Chapter 17 ”SPC for nonmanufacturing