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.
Dennis Quaid’s newborns reportedly harmed by medical mix-up – Los Angeles Times (Updated 4:57 PM, again at 9:51 PM, see bottom of post) If this story sounds familiar, it’s because it is the exact same error as one that killed…
The Sun Chronicle Online – Opinion A medical error was in the news this week, a teacher was mistakenly given an insulin shot instead of a flu vaccine. Thankfully for the teacher, it’s not even something they had to be…
The Lean Thinker » What Nukes? I had been mulling over trying to do a post on this story since the original story broke in August that some nuclear-armed cruise missiles were “accidentally” or “mistakenly” moved from one base in…
In the October 29, 2007 issue of FORTUNE, there is their weekly “How I Work” segment that profiles and/or glorifies an executive. This time it is Bobby Kotick, CEO of videogame maker Activision. They’ve evolved from Atari 2600 “tapes,” to…
SaukValley.com – Serving Dixon, Sterling & Rock Falls: Here’s a news story about career day at a High School and someone talking about Lean (I guess Wahl, the clipper company, is using Lean): “‘Poka yoke … allows you to dummy-proof…
Huge Price Paid for Stupid, Careless Medical Error | Tortdeform Lots of discussion of the sad case of the mixed up laboratory specimens and Darrie Eason having the unnecessary double mastectomy. One comment (from a reader of the blog I…
‘I don’t want this to happen to anyone else’ This will happen again, unless the process is fixed. Lean can help. Please read on… I heard about this story this morning, this horrible tragedy where a 35-year old woman, Darrie…
Patient Safety Blog – Telling Our Stories Here is an unfortunate story about a surgeon operating on the wrong side of an 86 year-old man, who died sooner after. There’s no clear cause-and-effect between that error and death: The surgeon…
How would you error proof this material handling / logistics situation? I have a few ideas, but thought this would make for interesting discussion. I won’t set up a “spend no money” rule, but cheaper and simpler ideas are always…
I don’t know if this is a new Gmail feature, or if I just discovered it, but there’s some nice error proofing built into the web-based mail application. If it detects the word “attached” in an email body, but there’s…
Thursday: Newer pools minimize risk of drain accidents, officials say You might have seen this heartbreaking story on the news, the 6 year-old girl who suffered gruesome injuries from a swimming pool drain. These tragedies are somewhat common, when viewed…
Cubicle Culture – WSJ.com: As the WSJ article mentions, my wife’s purse sometimes calls me… her Blackberry sometimes calls me if she didn’t put the keylock feature on. “Candy-bar style phones, with their keypads exposed, historically have been the culprits.…
