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.
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 tripped up by a preventable error – the Presidential limousine was mistakenly filled with diesel fuel…
Here in New Orleans, there was a problem with the city water today and there’s a 24-hour “boil water” order in effect through tomorrow morning. We could play a good game of the 5 Whys: Why can’t we drink the…
I saw this at an office supply store today (but didn’t buy it). For all of the coffee-making problems I have, tipping mugs over isn’t one of them (knock on wood). This mug is advertised as having a clever mechanism…
You might recall my post from July 2012 (“I Wish American Airlines Would Error Proof This on Their Website“) where I pointed out how easy it was for an American Airlines customer to accidentally cancel the wrong flight (an error I…
Hat tip to one of my favorite blogs, Uni-Watch.com, for pointing this out. In Sunday’s Texans / Patriots game, somebody on the Texans sideline apparently removed the red “challenge” flag from the back pocket of head coach Gary Kubiak. This…
tl;dr: A simple coffee mishap–placing a mug upside down under a Keurig–illustrates a core Lean lesson: human error is inevitable, so blaming people doesn’t help. Instead, good systems are designed to anticipate mistakes and prevent harm, reflecting Lean’s principle of…
Reflecting more on my recent Japan tour (see previous posts) one word came up in my notes: artifacts. One dictionary definition of that term is straightforward: “any object made by human beings, especially with a view to subsequent use.” Another…
Here’s an interesting story from this week: “Google early earnings release stuns traders.” Reportedly, the Google financial report for Wall Street was mistakenly released EARLY. Instead of releasing after the close of trading, it was sent out by R.R. Donnelly,…
One thing I have enjoyed in the past few years is meeting and working with more people with direct experience working at Toyota (including here in San Antonio, my new home). There are always gems and brilliant nuggets that come…
Preventable medical mistakes remain one of the most serious challenges in healthcare, yet many hospitals still struggle with learning from medical errors and preventing them from happening again. From emergency departments to pathology labs, the same types of errors continue…
As a frequent flyer on American Airlines, I often have five or six itineraries booked at a time. Unfortunately, the poor design of the American Airlines website includes the risk that I might cancel the wrong itinerary and flight. The Lean principle of mistake proofing would go a long way... and I'm sure a simple bit of programming could easily alleviate this risk.
Last weekend, I watched a show on the Smithsonian Channel that was an interesting contrast to the CNN show I blogged about yesterday (“A Lean Guy Watches “CNN’s 25 Shocking Medical Mistakes“). The Smithsonian show was about aviation safety: “AIR…
