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.

Why Did Some Patients Get Injected With 5X the Pfizer Covid...

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Before I get into this post, I want to also point you to another post that I wrote for the Value Capture blog: Salem Health...

When ‘Human Error’ Is the Answer, You Stopped Asking Why Too...

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TL;DR: Blaming "human error" is where root cause analysis goes to die. Keep asking why -- the system made the error possible, and the...

When the Wrong House Is Demolished: A Failure of Process, Not...

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TL;DR: When the wrong house gets demolished--again--it's not a rogue worker problem. It's a system and verification failure. Blame doesn't prevent recurrence; better process...

Everyday Kaizen While Traveling: Learning from Mistakes, Fatigue, and Airport Processes

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Many of you have asked if I'm at the AME Conference this week in Chicago. I am not, as I had a previous invitation...

Lessons in Lean, Culture, and Metrics from My First Trip to...

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tl;dr: I recently returned from my first visit to Brazil, where I spoke at a Lean Six Sigma conference, led a workshop on Process...

A Lack of Standardized Calendars Contributes to my Scheduling Mistake

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TL;DR: A non-standard calendar layout caused me to book the wrong tour date. When the same mistake happens repeatedly to different people, it's not...

Why You Can’t Undo a Simple Mistake in Excel — and...

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TL;DR: Lean is about designing systems that make it easy to do the right thing and hard to do the wrong thing. When software...

How Checklists and Andon Thinking Prevent Webinar Mistakes–and Help Teams Learn

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tl;dr: Checklists don't prevent mistakes unless people actually use them, and they work best in cultures where it's safe to speak up. A missed...

Forgetting Socks, Human Error, and Why Better Systems Matter More Than...

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tl;dr: Human error is inevitable--even for experienced professionals. Forgetting socks on a work trip is harmless, but similar mistakes in healthcare or organizations can...

So, I Finally Left an iPad Behind in an Airplane Seatback...

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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...

Throwback Thursday: This is Not a Drill — It Happened Again

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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...

The Academy Awards Add an Inspector, Practice “Andon Cord Pulls,” Avoid...

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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?
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