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.
Thankfully, it was nothing harmful or that dangerous… but I committed a medical mistake on myself last Saturday. I tweaked my lower back last Wednesday – something that, thankfully, isn’t a chronic problem (but I did just turn 40). It…
One of the more trivial things I saw on my recent vacation to Scotland and England was a badly designed toilet on a Virgin train. My wife and I were on our way to Birmingham to do a Range Rover…
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! Check out his blog, Improve with Me. By Brian Buck: Before I get into the topic…
Thursday night, we saw the type of error that happens every few years in the NFL… a player, Danny Trevathan, of the Denver Broncos, was about to score an easy touchdown, yet he dropped the ball, celebrating early, before crossing…
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. Kim Carnes’ (not to be confused with ThedaCare’s Kim Barnas) tops the charts for the year…
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 about a bit last week, my wife and I recently spent two days in Sonoma County…
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 Little League field (click here for better views and an article about this). My first thought…
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 is the National SECURITY Agency so bad at securing its own information? They’re better at…
I had a speaking engagement yesterday for a large system, with the audience consisting mainly of hospital CEOs and CFOs. I was able to be around for the entire morning, which included a really outstanding kickoff talk by the system…
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 than 18 hours of sunlight each day, to boot. I will blog more substantively about my…
Mistake-proofing vs. warning signs is not a close contest. Signs rely on people paying attention in the moment. Mistake-proofing removes the chance to fail in the first place. My friend Chad Walters has contributed guest posts to my blog (and…
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, hard working nurses out there. Nursing is important, difficult work. Sadly, the work is made more…