Thanks to Tom
Any built-in method or tool that prevents operators from making mistakes.
But, click on the link for an interesting example from a famous rock band. In the example, the “root cause” isn't error proofed, but they had an interesting way of predicting if an error was going to be made with the stage/show setup.
I also found her definition of a french cooking term, mise-en-place.
I've learned this term in some cooking classes (and my favorite cooking instructor, Gwen Ashley Walters
I love her quote from a famous chef, this could apply to a factory (or operating room) just as easily:
The universe is in order when your station is set up the way you like it: you know where to find everything with your eyes closed, everything you need during the shift is at the ready at arm's length, your defenses are deployed. If you let your mise-en-place run down, get dirty and disorganized, you'll quickly find yourself spinning in place and calling for backup.”
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Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.
He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean.
Mark is also a Senior Advisor to the technology company KaiNexus.