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.
So Monday’s blog post was about preventable medical errors – namely errors involving pharmacies giving the wrong meds or wrong doses to patients. That’s not rocket science – it’s a clearly preventable error. But it’s also something to not blame…
Just before the new year, the St. Louis Post-Dispatch featured the Lean efforts at Barnes-Jewish Hospital (“St. Louis hospital among handful using efficiency to aid patients“). I think it’s more than a “handful” of hospitals around the world using Lean…
I recently ran across a Michigan startup company called OPS Solutions that has some interesting technology that could be applied in many settings for standardized work and error proofing applications. Michigan is my home state and I’m always interested in…
This blog post is about my first visit to TMMTX in 2010.
A number of readers emailed me a link to this New York Times article: “U.S. Inaction Lets Look-Alike Tubes Kill Patients.” The headline emphasizes the lack of governmental oversight, but I’d rather talk about the poor system design that allows…
Here are a few events I’ll be a part of in the next few months, maybe I’ll see you there: Cindy Jimmerson’s “Big Sky” Lean Leadership Retreat, Sept 20-22 Michigan Lean Consortium’s Lean Healthcare Event, Sept 28 LEI “Key Concepts…
The other day, I had a DirecTV service tech coming to the house to make a repair (their customer service has been FAR better than my recent experiences with Verizon, I’m happy to say). I received a “robo-call” the day…
This is a cliche’ of bad process and bad information systems, but I actually received a paper check in the mail from Yahoo! for ZERO cents. ZERO dollars and ZERO cents. $0.00. I guess this is something that CEO Carol…
About a week ago, I was flying, and the passenger beside me knocked his water over right into my lap. Argh! I sent a Tweet posing a “contest with no prize” (as I didn’t want to stifle creativity with an…
Error proofing (aka “poka yoke” or mistake proofing) is such a powerful Lean method. Some people, unfortunately, think that Lean is only about speed or efficiency or cost. Going back to Toyota, the two pillars of TPS are Just…
Saturday morning, as part of my preparation to cook for a brunch gathering (I really enjoy cooking as a hobby, for those who don’t know me), I took a trip to a Boston Whole Foods location. One ingredient I needed…
I’m sitting here on a Sunday morning, drinking a cup of coffee I made at home with bottled water. Why bottled water? Because of a massive water main burst west of Boston – Boston and 30+ other communities currently have…
