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.
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?
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?
When I was on vacation, my wife and I rented an apartment in Beaune, France, instead of getting a hotel room. At left is a picture from the center of town. It was nice to be able to wash clothes…
This article from the Toronto Star caught my eye the other day: Cyclist says his pool noodle makes Toronto streets safer for him There was a law passed in Ontario requiring drivers leave one meter of space between them and…
Here’s an article that was sent to me by Dave Sundahl, who was my guest on Episode #86 of my podcast: The Deadly Results Of Flawed Design From the article: “Design has the power to make our lives better, and…
Gwendolyn Galsworth is a leading thinker and author on Lean and various aspects of "visuality." One thing she talks about in the workplace is "information deficits."
Last Thursday, I flew to Ohio after my 93-year-old grandfather was moved from the hospital to hospice. He passed away peacefully Saturday morning in the company of my dad and his three siblings. So, I have a heavy heart even…
I think I’m done complaining about Frontier Communications on Twitter. It’s been a very frustrating week, as I’m on day 6 of a complete internet outage. You can read my long rant about it here on LinkedIn: How Frontier Communications…
Later today and tomorrow, I’ll be attending the annual World Patient Safety, Science & Technology Summit that’s produced by a non-profit called the Patient Safety Movement. If you’re also at the event, please say hi! Follow the event on the…
