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.
tl;dr: The Boeing 737 MAX incident wasn’t caused by careless workers. It was the predictable result of weak systems, rushed production, poor mistake-proofing, and a culture that discourages speaking up. Blaming individuals prevents learning; fixing systems prevents recurrence. As we…
TL;DR: The phrase “mistakes are proof you’re trying” is true in some settings and dangerously misleading in others. In innovation work — product development, marketing experiments, learning new skills — mistakes are often part of growth and should be expected,…
Update: I’ve written a longer piece about inspection that’s now at the bottom of this post. I’m frustrated that the official Boeing response to their high-profile quality problems (and safety risks) is more… INSPECTIONS! Boeing will inspect Boeing’s work more.…
I was excited to host and moderate this recent webinar on January 17th at 1 pm ET. Register using the link below to view the recording of the session–it’s free: A Poka-Yoke Primer: Mistake-Proofing and Error Reduction It was presented…
This post is built around excerpts from the book The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. Read more about Toyota, including stories and key lessons learned in the book. Download a free preview of the book…
tl;dr: In this post, Mark explores the concept of the Plimsoll Line as a form of mistake-proofing in the maritime industry. He delves into its history and function in preventing the overloading of ships, drawing parallels to Lean principles of…
My new book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, is still only in a draft state before final proofreading (actually, the proofreading is taking place now). UPDATE — the paperback and hardcover books are…
I am saddened to hear of the death of Ritsuo Shingo (1947-2023), as announced by the Shingo Institute. He was the son of Shigeo Shingo, for whom the Shingo Prize and Shingo Institute were named. I want to express my…
Mistake-proofing shows up in everyday life more often than we realize–and a recent trip to the gas station reminded me why it matters. Chapter 4 of my book The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation…
TL;DR: Punishing people for mistakes does not reduce mistakes — it suppresses reporting, drives fear, and blocks learning. Evidence from healthcare, safety science, and organizations like Alcoa shows that improvement comes from systems thinking, transparency, and psychological safety, not blame.…
My guest for Episode #462 of the Lean Blog Interviews Podcast is Professor John Grout, the former dean of the Campbell School of Business at Berry College in Rome, Georgia. He was recently a guest on “My Favorite Mistake” — Episode 186, so I…
This week’s episode of the My Favorite Mistake podcast has a guest and a conversation that will be very directly relevant to you as a Lean practitioner. I hope you’ll check it out: Within the next month, John is also…
