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.
I’m sitting here on a Sunday morning, drinking a cup of coffee I made at home with bottled water. Why bottled water? Because of a massive water main burst west of Boston – Boston and 30+ other communities currently have…
I saw this on the national cable news two nights ago, the horrifying story of a Denton TX woman whose house was basically destroyed by a bulldozer. Was it a runaway bulldozer? Nope, different type of “accident.” Workers were supposed…
I’m blogging notes and thoughts as I watch the Discovery Channel documentary by actor Dennis Quaid and others — “Chasing Zero: Winning the War on Healthcare Harm” that first aired April 24 at 8 am EDT. With laptop and…
You might be familiar with the case where the actor Dennis Quaid’s twins were harmed by an overdose at the famed Cedar-Sinai Hospital in Los Angeles. I blogged about it originally in late 2007 as the post “How Often Must…
Note: I edited the post title on April 3 to make it clear this was an April Fool’s Joke. Comments posted by readers on 4/1 and 4/2 may have been “fooled” – thanks for taking the joke in good spirits.…
I’m a very frequent computer user and I’m pretty good with the ole’ shortcut keys, on both Mac and Windows (I’m bi-lingual). I remember when I’ve had hospital teams as clients, I’d often show them how to do basic things…
In recent years, healthcare has been learning a lot of lessons from aviation — including checklists and “Crew Resource Management,” as written about in the excellent books The Checklist Manifesto and Why Hospitals Should Fly. Aviation has gotten much…
Hat tip to my friend Jack for pointing out these short videos from the Pittsburgh Regional Health Initiative (PRHI) that they call “Teachable Moments.” The first video I saw was just about 3 minutes long, perfect for YouTube and Twitter-era…
Today’s post is a few Friday odds and ends about a new thing I’ve been involved, events I’m attending, and a new book I’m anxious to read (after I’m done reading a favorite old one).
When I was in Sweden, the one hospital I visited had an automated coffee machine that made a variety of drinks. In getting a cup of coffee, or trying, I found an example of everyday error proofing. When I first…
On Twitter last week, Tom Peters wrote: This is the wrong premise – it’s not that doctors (and nurses, for that matter) aren’t smart or that they haven’t been taught that hand hygiene is important. The right question should be…
Update (1/7/10): Turns out the TSA agent walked away from his post. I’d certainly hold someone accountable for that, since it was a conscious choice, unless there were VERY extenuating circumstances. After seeing the news on CNN last night (video…