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.

Boeing: “You Get an Inspection! Everybody Gets an Inspection!” [Updated]

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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...

Embracing Poka-Yoke: The Art of Mistake-Proofing, a Preview of John Grout’s...

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I was excited to host and moderate this recent webinar on January 17th at 1 pm ET. Register using the link below to view...

Mastering Mistake-Proofing: Insights from Toyota’s Poka Yoke Approach

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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,...

The Plimsoll Line: Mistake Proofing the Overloading of Ships

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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...

A Near Miss with Amazon’s Publishing Platform – Save Draft or...

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My new book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, is still only in a draft state before final...

In Memoriam: Ritsuo Shingo, Former Toyota Executive and Lean Teacher

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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...

Mistake-Proofing at the Gas Pump: Why I Didn’t Forget My Credit...

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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...

You Can’t Punish Your Way to Perfection: Why Blame Fails and...

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TL;DR: Punishing people for mistakes does not reduce mistakes -- it suppresses reporting, drives fear, and blocks learning. Evidence from healthcare, safety science, and...

Professor John Grout, A Deep Dive On Mistake Proofing And Lean

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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...

Mistake Proofing Expert John Grout’s Favorite Mistake and How to Prevent...

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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...

Lean Mistake Proofing Lessons from Credit Card Website Design

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Mistake proofing is one of the most practical--and most misunderstood--ideas in Lean thinking. It's often treated as a tool or device, but at its...

Why Medication Error Proofing Matters–Lessons from COVID Vaccine Administration

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TL;DR: Medication and vaccine errors don't happen because people are careless--they happen when systems make mistakes possible. This post looks at COVID vaccination examples...
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