Visual Management and Mistake-Proofing for Prescription Pills

Good ideas often just require some sensible thought to think of an improved approach. Management concepts can help guide such thinking, such as mistake-proofing and visual management.

To apply visual management requires giving a bit of thought to how to make visually obvious what is important for people to know. Mistake proofing is often really mistake-making-more-difficult (for some reason this term of mine hasn’t caught on).

prescription pills packaged together

Image from PillPack, they provide a service to deliver packages based on your prescriptions.

I believe mistake-proofing should put barriers in the process that make a mistake hard. Often what is called mistake-proofing doesn’t really fit that definition. The pill package shown above for example, doesn’t prevent you from continuing past the time on the package (Monday at 8AM) without taking the pills.

To call it mistake-proofing I would like to see something that makes it harder to make the mistake of failing to take the pills: something that blocks progress beyond that time without taking the pills.

Even something as simple as an alert to your smart phone that gets your attention and doesn’t allow the smart phone to be used without indicating you have taken the pills would reach the “mistake-proofing” level in my opinion (for someone that has their phone with them at all times). The Apple Watch could be a good tool to use in this case. Even so those wouldn’t make mistakes impossible (you can say you took the pills even if you didn’t, the phone/watch may lose power…). It would depend on the situation; this smart phone/watch solution is not going to be good for some people.

Another idea is that these pill packages should be tied to the room (in a hospital) and at home if a home care nurse (or even family or others) are responsible for assuring the pills are taken with a big display that perhaps 30 minutes before the pill is due posts a message that says “pills to be taken at 8 AM” and once that time is past it could become more obvious, perhaps after 15 minutes it produces an audio alert. The actual solutions are going to be better from those that know the actual situation than someone like me just thinking up stuff as I type.

But the idea is pretty simple: when you have processes that are important and at risk of failure, design processes with elements to make mistakes hard (and ideas such as mistake-proofing and visual management can help you guide your mind to ways to create better processes).

The entire process needs to be considered. The pill packages are nice, because even in failure modes they provide good feedback: you may still fail to take them at the right time, but you can look at the location where the pill packages are kept and see
if any have a time before right now (in which case you can follow the medical guidance – take the pills right now, contact the doctor, or whatever that advice is). Of course even that isn’t foolproof, you could have put the package into your purse and it is still sitting in their but you forgot.

Still the pill packages seem like a good mistake-making-more-difficult solution. And it seems to me that process has room to make mistakes even more difficult (using a smartphone addition, for example).

Continual improvement requires a continual focus on the process and the end user for ways to increase reliability and value. Each process in question should have engaged people with the proper skills and freedom to act using their knowledge to address weakness in the current process that are most critical.

Failure to take prescriptions as directed in a common problem in health care. Knowing this should make those involved in the process think of how they can use concepts, such as mistake-proofing, to improve the results of the system.

Too often to much focus is on making better pills compared to the effort is put into how to improve results with simple concepts such as visual management and mistake-proofing.

Each small improvement contributes to creating a more robust and effective process. And engaged people should continually access how the containing systems, new processes and new capabilities may allow more small steps to provide value to those relying on your products and services.

Related: Great Visual Instruction Example for Taking PillsVisual Management with Brown M&MsQuick Mistake Proofing Ideas for Preventing Date Entry Error

Another idea I thought of while writing this post: maybe it would be worthwhile to show a visual of the pills that should be in the bag. I think many pills are designed with colors and styles to look distinctive. Those closer to the process need to examine if this would be wise. I am sure it would be a bother, but maybe it would be a bother worth the trouble, or maybe not.

Those visuals of the pills seems like it would be the best from a perspective of making it easy on users. But sometimes process limitations make you adjust your current desired solution to something not quite as good but still worthwhile. If it won’t work to do that right now, perhaps there could be a page that shows what each pill in the entire (for example 1 month shipment) looked like, so you could look at that if you questioned if one of your pills was the right one. Also building on that, if your dosage changed or new pills were substituted, the monthly mailing could highlight those new pills with visuals.

Coming up with ideas for improvement isn’t hard. Many organizations have processes that make testing and adopting improvements (using the Plan Do Study Act cycle for example) very hard though.

In evaluating a good process and a good mistake-making-more-difficult measure I like to have the process degrade as gracefully as possible. So if the system completely relies on a smart phone and the user forgets their smart phone half the time or goes to areas where a signal doesn’t reach (and the solution requires a signal, versus being an app that is self contained) it doesn’t degrade very well without some additional measure.

I like how the paper pill package, if the pills aren’t taken provides the evidence that it was missed. One of the problems of taking them just out of the bottle is you have no indication of when they were last taken (though I believe some bottles have integrated some time indication on them – though I have also heard TSA in the USA may not allow such bottles – their rules say pills must be in the original prescription bottle).

Many people use those containers that have compartments with the days of the week and put all their pills in them. This seems good, but the pill package seems to me to improve a bit on that (various things, such as a person has to fill that up each week and they may well make a mistake, the packages have the pills that should be there written on them…).

I mentioned above that a problem with just looking at the next package to take is that you may have taken a package to work in your purse and forgotten you didn’t take them. The process could be improved by having you also store the used packages. They could even provide a template showing the packages that should exist (in case you have a confusing number of items to take). As usual what makes sense will depend on the needs of the users – I don’t know if such a template for used packages would make sense (it might for a very small percentage of users in which case it is so easy it may well be a good design element to incorporate). Again that template idea is just using the concept of 5s to make visible what is important.

4 thoughts on “Visual Management and Mistake-Proofing for Prescription Pills

  1. I don’t believe I’m stupid. At least my friends don’t tell me that I am. But like all humans I still make mistakes. In this respect I agree with Shingo. Employees don’t make errors because they are incompetent. Rather errors occur due to lapses in attention. What is at fault is the system, not the operator. Poka-yoke builds the function of a check-list into an operation so we can never “forget what we have forgotten.” I follow four steps to develop these:

    1. Control upstream, as close to the source of the potential defect as possible.

    2. Establish controls in relation to the severity of the problem.

    3. Think smart and small.

    4. Don’t delay improvement by over analysing.

    Finally, don’t underestimate the intellectual capacity of those who perform the work. Get the team involved.

  2. Two more examples of mistake-making-less-easy:

    – my father taught me to keep my wallet in my hands if you give your credit card or driver’s license or something to someone else. That way you don’t forget to get it back. I extend this to my passport. I carry the passport in a protector and keep that in my hands if I give the passport to someone (checking into a hotel etc.). It works, I have several times had to remind people to give identification back before I left.

    – copying and pasting a url instead of typing it. I will put the url in the browser and pull up the webpage and then copy it from the browser window before I past it into a document. I also copy my email address from my email web page rather than typing it out. Both methods eliminate typos.

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