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.

If a Toilet Requires Instructions, It’s Probably Badly Designed

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One of the more trivial things I saw on my recent vacation to Scotland and England was a badly designed toilet on a Virgin...

Detect Instead Of Inspect

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Mark's Note: Today's post is by Brian Buck, a long-time friend of this blog and a frequent contributor of some very funny Lean Memes!...

NFL Player Drops the Ball at the Goal Line: A Lesson...

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Thursday night, we saw the type of error that happens every few years in the NFL... a player, Danny Trevathan, of the Denver Broncos,...

Brilliant 1981 Article: “Why Japanese factories work” – Relevant for Healthcare...

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The year is 1981. A Major League Baseball strike interrupts the season. We're in the midst of the Cold War. President Reagan is shot....

Gemba Wine: A Lean Geek Visits Wineries, Part 2

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Growing grapes and making wine is certainly an art... but when you look into it there's a lot of process involved. As I wrote...

I Thought Major League Baseball Error Proofed Against This

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Wednesday night's game between the Cincinnati Reds and the San Francisco Giants had some batter's box lines that would have been embarrassing on a...

Snowden-Proofing the NSA

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Regardless of whether you think the NSA leaks that Edward Snowden admitted to make him a hero or a traitor, it begs the question: How...

#Lean Healthcare: The Really Good, the Sort of Bad, and the...

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I had a speaking engagement yesterday for a large system, with the audience consisting mainly of hospital CEOs and CFOs. I was able to...

I Wholeheartedly Approve the Violation of this Visual Control

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I've had a really nice time during my first 30 hours in Helsinki, Finland. It's been warm (72 F) and sunny -- and more...

Baseball and Ineffective Warning Tracks; Bryce Harping Running Into a Wall

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My friend Chad Walters has contributed guest posts to my blog (and has been a podcast guest), and I'm happy to return the favor...

Remembering the “Second Victims” of Medical Errors, Including Nurses

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This week, May 6-13, is National Nurses Week. It's always important, but it's especially good to thank and recognize all of the talented, caring,...

U.S. Presidential Limo Breaks Down Due to Fuel Filling Error in...

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From today's news: "Backup presidential limo on its way for Obama in Israel after fuel filling failure." U.S. President Barack Obama's trip to Israel was...
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