Washington "Natinals" Error
D.C. Sports Bog – Nationals Uniform Fail OK, Monday = sports day on the Lean Blog, apparently. I’ll get it out of my system today and get back to more traditional industries soon… This is a pretty systemic error when…
Tag Mistake-Proofing
Mistake-Proofing, Learning from Errors, and Safer Systems
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.
Error Proofing Against Pirates
Like many, I closely followed the recent pirate seizure of the Maersk ship with the American crew and was happy when the captain was free by the U.S. Navy. I wondered how a tiny boat with four pirates could board…
Misguided Error Proofing?
A core Lean concept is “error proofing.” We use physical devices or processes that make it difficult or impossible for errors to be made. For a great resource on error proofing, check out John Grout’s Poka-Yoke page. So let’s go…
Stop the Line in Healthcare: How Hospitals Are Adapting Toyota’s Andon for Patient Safety
TL;DR: “Toyota’s ‘stop the line’ concept is being adapted for healthcare — empowering any staff member to pause a procedure when something seems wrong, before it becomes a harm event. A surgical tech suspects the wrong patient has been brought…
Error Proofing To Ensure Hospital Staff Handwashing?
Hand washing and proper hand hygiene is a big concern at most hospitals — thankfully so, since hand hygiene and other basic infection control measures can save lives, preventing or slowing the spread of harmful bugs like MRSA and C-Diff,…
Dr. Berwick and Lean in Business Week
Donald Berwick: Curing the Healthcare System – BusinessWeek Good exposure for the applicability and use of Lean concepts in healthcare in BusinessWeek. Dr. Berwick is the head of the Institute for Healthcare Improvement (based in Cambridge, coincidentally, like the Lean…
Lost in Space
My Way News – Lost tool bag forces changes to planned spacewalks This makes wonder if the space program uses any concepts that we’d call “Lean” even if they don’t. This story makes me think of Error Proofing, Standardized Work,…
Weekend Fun: Google Mail Goggles
Official Gmail Blog: New in Labs: Stop sending mail you later regret Ha, this isn’t an “error proofing” service I would need anymore, but it might be helpful for our younger (say early 20’s) readers. It’s a google Gmail setting…
Pizza Hut Found a Root Cause?
No, this is not about the root cause of mediocre “pizza.” I got an email from Pizza Hut, which is strange, since I can’t remember the last time I’ve ordered anything from them. It read: You may have received an…
Unnecessary "Be Careful" Labeling?
Not long ago, I purchased a universal airplane/auto adapter. There was a packaging insert that exhorted me, the user, to NOT insert the plug the wrong way. There was even a “helpful” green line to help me line up the…
"More Careful" or "Better Processes"?
NHS: 60,000 medication blunders in 18 months – Health News, Health & Wellbeing – The Independent Trust me, I’m not picking on the NHS. There’s a lot of good things happening here with Lean and I’ll blog about some of…
Surgical Checklists in the News!
WHO Proposes Checklist to Reduce Surgery Errors : NPR A surgical revolution: checklist that could prevent thousands of deaths Thanks to long-time readers Chet and Andrew for pointing out these similar stories, one from NPR in the U.S. and one…
