Third Time’s the Charm for the Iced Tea — On Errors, Blame, and Process

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This past weekend, an old friend came down from Michigan to spend two days in the Dallas area.

Amongst the activities and catching up, we went bowling — something I did a lot of as a kid and something my friend and I usually do when we get together.

I ordered a drink — not a Lean whiskey, perhaps surprisingly — but this:

“An UN-sweetened iced tea, please”

That's what I said. Not that exciting, I know. We were going to a concert later and I was driving, so I was being careful.

After a frame in the first game of bowling, I took a sip of the tea. Bleccccch, it was SWEET tea.


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These things happen. Nothing to get upset over. I bet it was a process problem, I thought.

The server, she was mortified.

“I'm so sorry, I must have poured the wrong one by mistake,” she said.

I thought she had misheard me, since “sweet” and “unsweet” might sound similar in a loud bowling alley. The ordering of tea isn't error proofed like ordering whiskey “neat” or “on the rocks.” Those two options sound very different… unless somebody increases the risk of error by saying “whiskey, no ice” — a violation of “standard work,” LOL:

Back to bowling and my tea. A few minutes later, I get back from the lane and see another tea there. AGAIN, it was sweet tea.

When the server came by, I pointed this out and said, giving her the benefit of the doubt:

“Somebody must have mislabeled the dispensers.”

Now, I guess that still sounds like blame, but I wasn't blaming her.

She came back with a third attempt… it was unsweet tea, finally. She said,

“One of the new people put the wrong brew pack in the tea maker.”

It sounds like she was stating facts there, but it still sounds a bit blame-y.

She first blamed herself… then realized that she hadn't been set up for success.

In healthcare, I've seen people tend to blame themselves for systemic problems. Maybe they blame themselves because they care so much and they mean so well. It's possible that they haven't been taught about the role of processes and systems. Perhaps the organization tends to blame people, so they're conditioned to put that on themselves.

If a new employee did indeed make that mistake, was there a lack of training? Are the containers poorly labeled? Are the brew packs poorly labeled if that was indeed the problem?

I've made similar mistakes in hotel rooms with the coffee packs:

As I type this in a hotel room, I noticed that the K-cups have bolder DECAF labeling and color now:

That's an improvement. It's still easy to grab the wrong one, but the packaging is now more clear. It's a form of error proofing, even if it's not going to be 100% effective.

That's because people, even when properly trained, still commit “slips” or mistakes. We're all human, we all make mistakes.

That's why packaging that matters more, like medications, have to be much more clearly distinguished. That's where better error proofing is necessary.

Back to another non-life-threatening coffee mistake, I've put a coffee mug under a brewer UPSIDE DOWN before.

We're all human. We all make mistakes… but some humans are funny, like the person who made me this mug, as I blogged about:

I still use that mug today. And, medication errors still occur in hospitals…

Back to the bowling alley, I wonder how the problem was fixed. Did they fix it? Will they prevent this from happening again — or are they doomed to make this mistake once in a while (bad luck) or every time they have a new employee (bad training)?

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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

2 Comments
  1. dan markovitz says

    This reminds me of the Isao Yoshino story when he messed up the paint station in a Toyota plant by putting the wrong paints/chemicals in the paint machines. His managers apologized to HIM for putting him in a position to make an error.

    1. Mark Graban says

      Thanks for sharing that, Dan. I wish more leaders felt that sort of responsibility to their employees.

      As our friend and former Toyota leader Darril Wilburn says, “Leaders are responsible for providing a system in which people can be successful.”

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