Mistake-proofing is not about blaming people or demanding perfection. It’s about designing systems that make errors less likely and make problems visible when they occur. This archive explores mistake-proofing as a leadership and system responsibility—across healthcare, aviation, manufacturing, and everyday work.
Through real-world examples, these posts show why signs, reminders, and “be careful” messages fail—and how better process design, learning, and respect for people lead to safer, more reliable outcomes.
A man named Donald Gough died in a Cardiff hospital in November 2022, four weeks after an insulin error during surgery. He was 77, a retired NHS radiographer who had spent more than 50 years working in the same health…
At the 2024 KaiNexicon (the KaiNexus user conference), I gave a talk called “Warning: Signs! From Cautionary Commands to Proactive Prevention” — a tour through the world of warning signs, why they don’t work very well, and what we can…
TL;DR: Emergency slide deployments happen far too often to be dismissed as “human error.” When a mistake repeats at scale, it’s a system design problem. This Delta incident shows why leaders must design processes that anticipate human fallibility–rather than blaming…
I’m excited to be presenting this webinar on February 12th at 1 pm ET as part of the KaiNexus Continuous Improvement webinar series: Mistake-Proofing in Action: Real-World Examples Across Industries The webinar description: “Are you looking for practical ways to…
Karen Martin and Mark Graban discuss mistake proofing in lean management, why “zero harm” is a meaningful aspiration, and how building quality at the source reduces errors without blaming people. Scroll down for how to subscribe, transcript, and more My…
What’s the difference between a mistake and an error? When people search “mistake vs error,” they’re usually asking whether the two words mean different things — or whether one implies more blame than the other. Short answer: In most contexts,…
Over the years, I’ve seen how often organizations respond to mistakes with blame, punishment, or superficial fixes–rather than learning and prevention. That’s why I collaborated with Karen Martin and TKMG Academy to create a mistake-proofing course focused not just on…
TL;DR: A simple lunch at Kura Revolving Sushi reveals how good design quietly prevents mistakes without blaming customers or staff. It’s a reminder that the best mistake-proofing doesn’t aim for perfection–it makes the right action easy and the wrong one…
The other day, I was presenting at a company about “Psychological Safety as a Pre-Condition for Continuous Improvement.” It was a hybrid event and I noticed, during the Q&A period, that somebody on Teams chatted about me making a mistake.…
TL;DR: Emails and warning signs rely on memory and attention. Point-of-use reminders–and better yet, mistake-proofed systems–are far more effective at preventing errors, as a simple condo trash chute failure illustrates. I often write and speak about how warning signs (or…
Thanks as always to Ryan McCormack for this… there’s always so much good reading, listening, and viewing shared here by him! Subscribe to get these directly from Ryan via email. News, articles, books, podcasts, and videos about how to make…
As I posted recently on LinkedIn, here are some photos and a story from years ago. Signs are not mistake-proofing. Signs are not adequate process controls. “Please do not park stretchers or carts in the hallway.” I’m quite certain that…
