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By December 20, 2012 13 Comments Read More →

My Human Error with my Keurig

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:

IMG 3403 375x500 My Human Error with my Keurig lean

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…

Happy Holidays!

 


mark graban lean blog My Human Error with my Keurig leanAbout 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.

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13 Comments on "My Human Error with my Keurig"

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  1. Alex Jones says:

    You could paint a big \”X\” on the bottom of all your coffee cups with red nail polish :)

    How do you like that Keurig, anyway? I have to go read that single-serve waste thread….

    • Mark Graban
      Twitter:
      says:

      Great error proofing suggestion, Alex!

      I like the Keurig… I did a cost/benefit analysis on a k-cup vs brewing even a 4-cup pot in a traditional coffeemaker… less wasted coffee with the Keurig, but there’s an environmental cost of the plastic disposal. I try to mitigate that a bit by sometimes using a reusable k-cup that you fill with your own grounds.

      I like the “quick changeover” of being able to make coffee, decaf, and tea all in a row if people want different beverages… but the coffee taste isn’t as good as a good old French Press (the FP being more time and more work).
      Mark Graban recently posted..Visiting and Teaching at Ohio State – Meeting Archie Griffin, Reflecting on Values and WinningMy Profile

  2. Interesting Mark. James Reason began to ponder human error when he was making a cup of tea and feeding the cat. He discovered that he had put the cat food in his teacup.

    Hmmm… both caffeinated beverages. Perhaps fatigue is an issue too.

    Merry Christmas my friend.

  3. Bob Graban says:

    Not quite one of these \”never events\” talked about in today\’s WSJ, but you can see how they can happen: Surgeons Make Thousands of Errors.

    My Keurig does have a sensor that won\’t let it start without a cup in place. I almost put a cup in upside down once, but caught it – it would be like pouring onto the bottom of the cup – smile! And that\’s why my Chevrolet Volt won\’t let me shift out of \”Park\” with the charge cord attached, although it does let me turn it on.

    • Mark Graban
      Twitter:
      says:

      Thanks, Dad – I hadn’t seen the WSJ article.

      Calling these “never events” is sort of wishful thinking like a “gun free zone.” Although, it’s probably easier to 100% eliminate medical errors than it would be to eliminate all shooting deaths.

      Interesting about your Keurig. You must have the Cadillac model :-)

      I guess the level of error proofing required depends on the risk and cost of the potential error. With your Volt, I’m sure that would cause a lot of damage to the car and your garage. The coffee maker, not so much damage or cost.

      We need to do more to error proof medicine, where the human cost and financial cost is far too high.

  4. Chad
    Twitter:
    says:

    Wow…rough day, huh?

  5. Mark Graban
    Twitter:
    says:

    This Quality Digest piece, about waiting times at Starbucks, is almost a parody of overcomplicating things with Six Sigma, but I think it’s on the level:

  6. Mike Thelen says:

    Hi Mark,

    Happy Holidays – sounds like you\’re ready!

    How about only buying coffee cups that are larger at the bottom than the top – not perfect, but asymetrical often creates sub-conscious action.

    Now I know what to send you for Christmas, a coffee cup with a big arrow and \”THIS SIDE UP\” printed on it :)

    All the best my friend!

  7. LOL. That\’s a great post! At least you didn\’t fire yourself over the \”mistake\”! Merry Christmas, Mark! Maybe see you in TX!
    Karen Martin recently posted..Metrics-Based Process Mapping: What, When & HowMy Profile

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