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.
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 core, mistake proofing reflects a leadership mindset: systems should be designed to anticipate human error, not…
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 to show why mistake-proofing, good process design, and psychological safety are essential to preventing harm in…
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 Presentation on Their Covid Vaccination Process and Lean Now, on to the injection mistakes discussion.…
TL;DR: Blaming “human error” is where root cause analysis goes to die. Keep asking why — the system made the error possible, and the system is what leaders can fix. When Covid vaccines first rolled out, the pressure to avoid…
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 design does. I can’t believe I’m writing about this again. But, I saw in the news…
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 to speak at the Swiss Lean Conference today. My theme was Kaizen — engaging everybody, everywhere,…
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 Behavior Charts, and visited two organizations applying Lean principles. From churrascarias to Gemba walks, this trip…
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 a personal failure–it’s a system design problem. Standardizing calendars and using mistake-proofing (poka-yoke) reduces errors far…
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 like Excel allows irreversible mistakes with a single misclick–and no meaningful confirmation or undo–it violates basic…
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 step in a webinar setup shows how Andon-style intervention–someone noticing a problem and saying something–can quickly…
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 cause real harm. The lesson isn’t to “be more careful,” but to design better systems that…
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 my first (and only) iPad in early 2014. I use many Apple products, but I’m…
