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.
Dan Evans’ VBA Scripts – Outlook Attachment Checker etc LifeHacker Post Have you ever composed an email, meaning to attach a file, even saying something like “see the attached file…” and then you forget to actually attach the file? I…
I could have also titled this post “I screwed up!” or “Who Screwed Up? Me!” but we try not to point the finger of blame in the Lean mindset…. it’s especially uncomfortable when you have to point it in the…
Another great thought from David Mann this week was highlighting how a Lean culture will “embrace it’s misses” rather than try to cover them up. His example was in the context of a production line not making it’s production goal…
By Dan MarkovitzBack in October, Lifehacker ran a lengthy article on “personal kaizen.” The thrust of the piece is how we can improve our lives by adopting the kaizen approach of the TPS and applying it to our own work…
Hospitals try to reduce wristband code risks To put this in manufacturing terms, imagine how you might have to change your process if your product might get transferred to another factory for additional processes. In recent years, hospitals have widely…
Here’s another example of “Everyday Error Proofing‘ courtesy of the new cable box from my cable company (part of the federally mandated transition to digital-only service). The manual for the remote says (not that I was reading it, but I…
Hazard Warning – Brethine and Methergine mix-ups Can you tell the difference between these two drugs? You can even click on each photo for a larger view or compare them on the link above. This isn’t an isolated case, this…
tl;dr: The andon cord isn’t a tool–it’s a trust signal. Toyota’s thousands of line stops reflect psychological safety and leadership support. Ford’s rare pulls reflected fear and mistrust. Lean succeeds or fails on culture, not mechanics. In 2007, a BBC…
By Dan Markovitz Sometimes it’s hard to spot errors in an office, much less error-proof the workspace. With so many value streams running through each knowledge worker, and so much of the value being intangible and invisible, error-proofing is tricky.…
Fatal Dose: Ohio Girl is Killed By Medical Mistake Here is a sad story of a girl’s death due to a hospital pharmacy mistake. Pharmacies oftentimes just repackage and dispense “off the shelf” drugs (such as pills), but they often…
Kevin, M.D. – Medical Weblog: A woman dies after receiving 8 grams of Dilantin I read about this on the blog linked above and the source article is here. A nurse administered an incorrect dose to a patient, TEN TIMES…
I was boarding an American Airlines Super 80 at DFW yesterday, I noticed a warning sign on the controls of the jet bridge. As I’ve said before, “warning signs are not error proofing.” That certainly applies here. There was a…
