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.
Did anybody else see this show hosted to Elizabeth Cohen on CNN last weekend, titled “25 Shocking Medical Mistakes“? You can see a video preview or read the transcript online. I’m not sure if the whole show is available online…
In prep for our move to San Antonio, my wife and I have been applying “5S” principles to our lives and possessions. We have gone through an intense “sort” process – deciding what to move and what to donate or…
As I’ve mentioned, my wife and I are in the process of moving from suburban Fort Worth to San Antonio. As we have potential buyers coming through the house, one thing I have to be mindful of is NOT turning…
Continuing this first week of the year’s theme of using Lean principles to improve our lives, I’m going to write about two pieces of technology that can help prevent two different types of health problems, particularly in the elderly. The…
People in healthcare know that miscommunications are a major cause of errors and patient harm. There was a strange footnote to game 5 of the World Series, where the Texas Rangers beat the St. Louis Cardinals 4-2. A miscommunication led…
Thanks to my friend and fellow author Karen Martin for taking this picture while in Calgary. Even if you don’t wear high heeled shoes, I think you can appreciate the attempt at error proofing. Karen and I both wondered if…
The two primary web browsers I use these days on my Mac are Safari and Chrome. I’ve always been a big user of keyboard shortcuts, whether in Microsoft Office or other software. In Safari, when trying to close a single…
A note from 2026: I wrote a fuller version of this same argument recently, with more sources and a fairer look at what Six Sigma actually offers. This post stays up because the comments below are still some of the…
“Progress isn’t made by early risers. It’s made by lazy men trying to find easier ways to do something.” – Robert Heinlein, American science fiction writer (July 7, 1907 – May 8, 1988) With “kaizen,” the Japanese word meaning “change…
After a week of serious topics and sometimes pointed discussion, let’s end with a funny sign… well wait, there’s a serious story behind this sign too. This is a sign from a New Zealand hospital, sent via email by a…
On a recent Sunday morning, I was watching cable news channels and two different commercials had a word jump out at me, words that are commonly used in the Lean management system. One commercial featured the term “mistake proofed” and…
In the news yesterday, a General Motors recall over what could be just one isolated steering wheel problem in an Ohio-built Chevrolet (don’t call it Chevy) Cruze. Most news stories, like this one, about the recall just mention that one…
