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.
snopes.com: Aluminum Foil Locking Tabs Here’s an interesting example of “Everyday Lean” that I never knew about. Have you ever been frustrated by pulling on a roll of aluminum foil (or plastic wrap) and having the roll pop out of…
Express Mail: USPS Says Guaranteed Overnight Isn’t Guaranteed. What? Saw this post on The Consumerist blog about how the United States Postal Service does NOT guarantee overnight delivery of “guaranteed” overnight documents…. IF you place the package in a drop…
Below is some of the text from edition #3 of the newsletter from my upcoming book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. ————————————— Hospitals are notorious for employing “workarounds” to respond to problems. For example, when supplies…
Mistake-proofing expert Martin Hinckley joins the podcast to explain why traditional inspection methods can’t catch rare mistakes — and what it actually takes to eliminate them. We cover the difference between mistakes and variation, the real meaning of poka-yoke, and…
Why do you need a “be careful” warning message when you’ve already error proofed something? For liability’s sake? I am going to be flying back and forth to the UK a lot this summer, so I needed an airplane power…
Dennis Quaid Recounts Twins’ Drug Ordeal, Actor Tells 60 Minutes’ Steve Kroft Medical Errors Kill Thousands – CBS News Did you see the actor Dennis Quaid on 60 Minutes last week? He talked about the sad case where his twin…
L.I. Hospital Scrutinized After Deaths of Patients – New York Times It wasn’t the same laboratory this time, but it’s more than likely a similar root cause. I wrote before about pathology specimen labeling errors, how they’re preventable human error.…
Urban Legends Reference Pages: Cruise Control on Wet Roads Hazard This is sort of an old urban legend that has been making the rounds again, but there’s some truth to it in that we shouldn’t use cruise control in our…
If you’re a regular reader, you might recall the Cedar-Sinai medical error that harmed Dennis Quad’s twins (and others). Quaid and his wife are now suing the maker of the drug, Baxter, claiming the company is negligent for not designing…
If you’ve been following any of the posts about healthcare, here are a few interesting follow ups. Following up on this post about Boston’s Beth Israel Deaconess Medical Center, CEO Paul Levy posted many interesting employee responses to his email…
I’m a bit mad at myself for inflicting some preventable human error on myself last night. It’s OK, I didn’t harm myself, but let me tell the story. I’ve been battling what’s either severe allergies or a mild cold for…
Here are some follow-up articles, quotes, and data following up on the news from the other day that Dennis Quaid’s twins were impacted by a medication error at L.A.’s Cedar-Sinai hospital. SEE MORE POSTS ABOUT THIS CASE This article points…
