Here’s a funny one… I was dragging a bit, working from home, and was ready for a mid-afternoon cup of coffee via my Keurig (see a great Evolving Excellence blog discussion – in the comments – about the waste or value of single cup makers.
I placed a mug under the spout and hit the brew button. I walked back over and it looked like the mug had overflowed.
My first thought was, “what’s wrong with the machine or that individual K-cup?” Sigh… my first instinct was to blame (although I’m not going to hurt the machine’s feelings). Shame on me for that.
I took a picture after grabbing the mug and realizing what had happened… I had placed the mug UPSIDE DOWN under the spout. See below:
You can see a brown spot from where the coffee had been sitting on top of the bottom of the mug. Most of the coffee ended up in the drain that’s underneath the mug.
Keurig could have placed a “Be More Careful” warning on the coffee machine, saying “ensure mug is right side up” but that might look ugly and get ignored anyway.
I could tape a sign on my cupboard door warning myself not to make this mistake (or any cooking error)… nah, that wouldn’t work (and it wouldn’t look good).
I’ve never made this particular mistake before. I guess I’m ready for some Christmas time off… this has never happened before and, after making this error, it’s probably unlikely to occur again (as I now jinx myself).
I don’t think “more training” (a common hospital countermeasure) about how to use the Keurig would be a worthwhile remedial measure. Should I suspend myself from making coffee for a week? Nah.
I’m laughing at myself because my human error shows how human we all are. Toyota’s “respect for people” principle, especially when called “respect for humanity,” emphasizes that people are human and we all make mistakes. We have to design systems that account for error (like putting a drain under the mug… helpful for times when the mug is upside down or a mug isn’t placed there at all).
The machine could have an expensive interlock where it doesn’t brew unless it detects the weight of a mug… but that would add too much cost for a problem that doesn’t occur that often.
Or, it just has to have a simple, inexpensive removable drain that prevents too much coffee from getting on the countertop.
Unlike medical errors (where people tend to get blamed or punished), this Keurig mishap didn’t harm anybody. There’s no voluntary “coffee making error reporting system” that requires me to post my mistake, but I have this blog… if I were still working at GM (circa 1995), I could have yelled at myself for my poor quality… but that doesn’t really help. I made another cup of coffee, correctly this time, and went on with my day…
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus.