Tag: Error Proofing

Guest Post: Poka Yoke… When It’s Personal

Guest Post: Poka Yoke… When It’s Personal

Mark’s Note: Today’s guest post is by Chris Burnham. I invited him to write this after I saw him share his pre-surgical “poka yoke” (or error proofing) on Twitter (caution: picture of feet). I asked him if “anybody was offended” by his abundance of caution and interest in not having the wrong foot operated on. […]

By October 8, 2014 4 Comments Read More →
Toyota’s Blog on Pillars of the Toyota Production System & Lean

Toyota’s Blog on Pillars of the Toyota Production System & Lean

I didn’t know , until yesterday, that Toyota has an official company blog (at least for Toyota UK). Even though I’ve learned from Toyota people and many books and classes (and I’ve written books of my own), I always encourage people to get Toyota Production System knowledge directly from the source whenever possible – including […]

Learning Not to Blame: Baseball Edition

Learning Not to Blame: Baseball Edition

Following up my post about not blaming a bartender, here’s another look at learning to cast aside our old habit of blaming individuals… this time, baseball related. Modern organizations (in healthcare and business) tend to blame an individual when something goes wrong. It’s commonplace in our societies and it’s, basically, human nature to blame. But, […]

A Whiteboard Accident Waiting to Happen – How to Error Proof?

A Whiteboard Accident Waiting to Happen – How to Error Proof?

Yesterday, Jim Benson and I were facilitating a “Lean for Knowledge Work” class at Geekdom in San Antonio and had a great time with attendees from healthcare and high tech companies. We facilitated some “Lean Coffee” discussion sessions in a conference room. While the format is facilitated with sticky notes and pens, I noticed the […]

Standardized Work? Why Are NFL Concussion Guidelines Not Always Followed?

Standardized Work? Why Are NFL Concussion Guidelines Not Always Followed?

Mark’s note: Ah, another NFL playoff weekend and time for another football post to follow up my apparent jinxing of the Eagles’ head coach Chip Kelly last week. Today’s guest post from Chad Walters is an intersection between sports, medicine, and Lean. Last weekend during the NFL playoffs, two players – David Bakhtiari of the […]

By January 11, 2014 9 Comments Read More →
My Medication Error on Myself

My Medication Error on Myself

Thankfully, it was nothing harmful or that dangerous… but I committed a medical mistake on myself last Saturday. I tweaked my lower back last Wednesday – something that, thankfully, isn’t a chronic problem (but I did just turn 40). It got progressively more painful over the next few days, so I went to an urgent […]

By November 15, 2013 5 Comments Read More →
If a Toilet Requires Instructions, It’s Probably Badly Designed

If a Toilet Requires Instructions, It’s Probably Badly Designed

One of the more trivial things I saw on my recent vacation to Scotland and England was a badly designed toilet on a Virgin train. My wife and I were on our way to Birmingham to do a Range Rover factory tour (something I’ll write about soon, along with some fun visits to scotch whisky […]

By November 12, 2013 10 Comments Read More →
Detect Instead Of Inspect

Detect Instead Of Inspect

Mark’s Note: I’m away on vacation through November 6… there will be some guest posts in this post during that time. Today’s post is by Brian Buck, a long-time friend of this blog and a frequent contributor of some very funny Lean Memes! Check out his blog, Improve with Me. By Brian Buck: Before I […]

By October 30, 2013 4 Comments Read More →
Denver Bronco Loses Touchdown for Not Following Standardized Work

Denver Bronco Loses Touchdown for Not Following Standardized Work

I’ll apologize in advance to those of you who don’t care about football. Thursday night, we saw the type of error that happens every few years in the NFL… a player,  Danny Trevathan, of the Denver Broncos, was about to score an easy touchdown, yet he dropped the ball, celebrating early, before crossing “the plane” […]

By September 9, 2013 8 Comments Read More →
Brilliant 1981 Article: “Why Japanese factories work” – Relevant for Healthcare in 2013

Brilliant 1981 Article: “Why Japanese factories work” – Relevant for Healthcare in 2013

The year is 1981. A Major League Baseball strike interrupts the season. We’re in the midst of the Cold War. President Reagan is shot. Kim Carnes’ (not to be confused with ThedaCare’s Kim Barnas) tops the charts for the year with “Bette Davis Eyes.” And, Toyota has zero manufacturing presence in the United States… yet. […]

By September 3, 2013 6 Comments Read More →
Gemba Wine: A Lean Geek Visits Wineries, Part 2

Gemba Wine: A Lean Geek Visits Wineries, Part 2

Growing grapes and making wine is certainly an art… but when you look into it there’s a lot of process involved. As I wrote about a bit last week, my wife and I recently spent two days in Sonoma County and two days in Napa County, California. She would cringe if I called these “gemba […]

By August 26, 2013 0 Comments Read More →
I Thought Major League Baseball Error Proofed Against This

I Thought Major League Baseball Error Proofed Against This

Wednesday night’s game between the Cincinnati Reds and the San Francisco Giants had some batter’s box lines that would have been embarrassing on a Little League field (click here for better views and an article about this). My first thought was “how hard is this to error proof?” There are $99 devices that allow one […]

Snowden-Proofing the NSA

Snowden-Proofing the NSA

Regardless of whether you think the NSA leaks that Edward Snowden admitted to make him a hero or a traitor, it begs the question: How is the National SECURITY Agency so bad at securing its own information? They’re better at snooping than securing, I guess. This article has an explanation:  NSA leaker Ed Snowden used […]

#Lean Healthcare: The Really Good, the Sort of Bad, and the Ugly

#Lean Healthcare: The Really Good, the Sort of Bad, and the Ugly

I had a speaking engagement yesterday for a large system, with the audience consisting mainly of hospital CEOs and CFOs. I was able to be around for the entire morning, which included a really outstanding kickoff talk by the system CEO (talking about process improvement as a key strategy) and followed by two internal P.I. […]

I Wholeheartedly Approve the Violation of this Visual Control

I Wholeheartedly Approve the Violation of this Visual Control

I’ve had a really nice time during my first 30 hours in Helsinki, Finland. It’s been warm (72 F) and sunny — and more than 18 hours of sunlight each day, to boot. I will blog more substantively about my gemba visit to a Helsinki-area hospital yesterday. But, I’ve had some really good food (lots […]

My Guest Post @LeanBlitz – Baseball and Warnings

My Guest Post @LeanBlitz – Baseball and Warnings

My friend Chad Walters has contributed guest posts to my blog (and has been a podcast guest) and I’m happy to return the favor with a guest post on his site: “Guest Post: A Clown Post About Bryce Harper and Warnings.” Since his “Lean Blitz” blog is sports themed, I wrote a post about warning […]

Remembering the “Second Victims” of Medical Errors, Including Nurses

Remembering the “Second Victims” of Medical Errors, Including Nurses

This week, May 6-13, is National Nurses Week. It’s always important, but it’s especially good to thank and recognize all of the talented, caring, hard working nurses out there. Nursing is important, difficult work. Sadly, the work is made more difficult than it should be due to bad processes and waste in the healthcare system. […]

U.S. Presidential Limo Breaks Down Due to Fuel Filling Error in Israel

U.S. Presidential Limo Breaks Down Due to Fuel Filling Error in Israel

From today’s news: “Backup presidential limo on its way for Obama in Israel after fuel filling failure.” U.S. President Barack Obama’s trip to Israel was tripped up by a preventable error – the Presidential  limousine  was mistakenly filled with diesel fuel instead of gasoline / petrol. One of the limousines in  Barack Obama’s fleet has […]