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.
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…
Lean is, of course, not about a better way to build cars. It's a transferrable philosophy, management system, and methodology that is being applied in many different settings and industries, including healthcare. I'm often told (sometimes by somebody who is being sort of huffy): "Patients are not cars." [...]
I’ve been studying and working with Lean for 20 years now and I love Lean because I’m still learning and getting better at this craft. I love seeing other people get excited about Lean when it’s new to them, when…
Here is my latest article for the LinkedIn “Influencers” series, written for a general audience that might not be as familiar with Lean: How These Credit Card Websites Illustrate Lean Mistake Proofing I hope you enjoy the article, even as…
Thanks to my friends in the Michigan Quality System group, the internal Lean group at the University of Michigan Health System. They shared a video that was put together by Dr. Jack Billi, a long-time student of Lean and advocate…
Every time I am in a hospital or clinic setting, one of the first things I do is get a pump or squirt of gel or foam from a wall-mounted dispenser to clean my hands. Or, I should say *try*…
Following up my earlier post about the “Patriot Way…” During her halftime extravaganza (video), Katy Perry had a silver strap around her wrist, attached to the microphone. It reminded me of the Nintendo Wii strap that helps prevent throwing the controller (Update:…
Mark’s Note: Today’s guest post is by Chris Burnham. I invited him to write this after I saw him share his pre-surgical “poka yoke” (or error proofing) on Twitter (caution: picture of feet). I asked him if “anybody was offended”…
I didn’t know , until yesterday, that Toyota has an official company blog (at least for Toyota UK). Even though I’ve learned from Toyota people and many books and classes (and I’ve written books of my own), I always encourage…
Following up my post about not blaming a bartender, here’s another look at learning to cast aside our old habit of blaming individuals… this time, baseball related. Modern organizations (in healthcare and business) tend to blame an individual when something…
Yesterday, Jim Benson and I were facilitating a “Lean for Knowledge Work” class at Geekdom in San Antonio and had a great time with attendees from healthcare and high tech companies. We facilitated some “Lean Coffee” discussion sessions in a…
Mark’s note: Ah, another NFL playoff weekend and time for another football post to follow up my apparent jinxing of the Eagles’ head coach Chip Kelly last week. Today’s guest post from Chad Walters is an intersection between sports, medicine,…
