Berry College professor John Grout said the idea for his recently published paper in the July issue of Joint Commission Journal of Quality and safety came to him "like a lightning bolt."

The paper, "Preventing Medical Errors by Designing Benign Failures," exoplores the concept of making health care procedures more resistant to human error.

"People will always make mistakes in repetivitve environments," Grout said

In his paper, he suggests that instead of focusing on individual performances of health care workers through "checks and redundancies," hospitals should design medical processes that "fail benignly" before a patient can be hurt.

Grout uses a water faucet as an example.

"A scald valve could be installed that restricts flow from the tap if the water temperature exceeds a certain level," he said.

The water shutting off would catch a nurse's attention and a patient receiving a bath avoids a possible scalding.

Before writing the article, Grout began to collect examples from hospitals to support his ideas.

Floyd Medical Center senior vice president Sonny Rigas was in Grout's class last year and provided Grout with examples of benign failure procedures at FMC.

"Dr. Grout is very right that if you can engineer the mistake-proofing up front, a lot of patient safety will come of it." Rigas said.

Grout hopes things he learned from hospital examples can be used at other hospitals to improve safety.

He plans to continue examining other hospitals for new procedures.

Grout, an associate professor of business administration, began in the field of mechanical mistake proofing and entered the medical field in 1996 when a doctor now at Columbia Presbyterian Hospital contacted him.

Grout began his paper after he presented his idea at a patient safety conference in October 2002.

Dale Carroll, director of nursing at Redmond Regional Medical Center, said her hospital is currently shifting from staff theories to system theories when looking at preventing medical mistakes.

"We are encouraging staff to report potential problem areas' so that mistakes cannot happen the next-time," Carroll said. "This will help us mistake proof the environment."

Grout also operates a Web site: www.mistakeproofing.com.