Tag: Mistake-Proofing

My wife recently had some work meetings in Louisville, Kentucky and she had a great idea... "Why don't you fly here on Thursday night...

Lean focuses on making it easy for people to do the right thing. We also work hard to "error proof" processes and our work...

For years, Dr. Greg Jacobson and I have used checklists when prepping for and running our various webinars via KaiNexus. You can join us...

Last week, I had the chance to teach and facilitate a Lean education session for a group of health system executives and physician leaders...

The "Miracle on the Hudson" was 10 years ago today. Read my blog post about hearing Sully speak at an event last year. I got...

I really don't enjoy the type of "Throwback Thursday" posts that are triggered by something in the news that reminds me of something that I've blogged about in the past. Sometimes, it seems people are doomed to keep repeating the same preventable errors instead of learning from others, improving systems, and mistake proofing things in life. In this post, we look back at repeated errors in pathology, building demolition, and emergency alert systems...

Tomorrow, my post will be about headlines that scream about ratings for The Oscars being "down from last year" or "the lowest in X years." As I've blogged about before, I'm always skeptical of such simplistic comparisons that might mask the real underlying trend. But first, could the Academy avoid last year's embarrassing mixup?

Saturday, you might have seen the news about a "false alarm" push alert that was sent to many iPhones and other smart phones in Hawaii. An alert was also sent out over many TV channels through the Emergency Response System. Is the response one that focuses on blame and punishment? Or is it focused on understanding how systems fail and how to improve them to prevent future recurrence? How does this all apply to your organization?

Are warning signs or instruction signs effective when they just tell people what to do? Should we use error proofing instead? Is it more powerful to explain why when we have be directive. That's what I explore in this post, with some examples from hospitals and a condo gym.

In recent years, I've written two blog posts about the sad scenarios where the wrong building was demolished by a crew. In these scenarios, it's easy to blame "bad crew" instead of looking at systemic causes of such an error. Having a better process is always more effective than admonishing people to "be more careful." What did I see recently that caught my attention in terms of trying to prevent demolition errors?

Mistake proofing is a core Lean / TPS concept that makes it harder for people to do the wrong thing. Ideally, we make it impossible for errors to occur. This might be easier in physical settings, but can also be done in the digital realm.

Alternative headline: “Poorly Designed Card Trips Up Beatty and Dunaway at The Oscars.” Or “A Bad Process Beats Warren Beatty Every Time.” What are the Lean lessons from this mistake?