Mistakes are inevitable—but how leaders and organizations respond to them determines whether they improve or repeat the same failures. These posts explore mistakes through a Lean lens: system design vs. “human error,” psychological safety, learning cultures, and leadership behaviors that turn errors into improvement rather than blame.
Drawing from healthcare, manufacturing, aviation, sports, and everyday work, this archive focuses less on who failed—and more on what the system made possible.
Mistakes are inevitable; learning is not. These posts align with ideas I expanded on in The Mistakes That Make Us, which examines how leaders, cultures, and systems determine whether errors become liabilities—or catalysts for improvement.
The other day, I had an external hard drive completely fail. I lost the last 10 days’ worth of data. That wasn’t supposed to happen. I had protections and backups in place… yet something still went horribly wrong. If you…
Thanks to my friend Brian Buck (and his co-host Catalina Park) for having me as the first guest in their podcast series (in previous episodes, it’s the two of them talking and sharing together). Their podcast (also a YouTube channel)…
While I’m mostly staying home because of the pandemic, I sometimes treat myself to a Starbucks beverage while I’m out running errands. I have traditionally been a black coffee drinker (blonde roast, mostly), which means my orders are easy and…
General Jim Mattis has been making the rounds to talk about his new book that is out today: Call Sign Chaos: Learning to Lead. “Learning to Lead” sounds like it could be the title of a book about Lean management.…
This past Saturday was, of course, the 50th anniversary of the first moon landing. It still puzzles me why mankind hasn’t been back on the moon in my lifetime — see an article about that. The first trip to the…
TL;DR: A non-standard calendar layout caused me to book the wrong tour date. When the same mistake happens repeatedly to different people, it’s not a personal failure–it’s a system design problem. Standardizing calendars and using mistake-proofing (poka-yoke) reduces errors far…
Speaking of mistakes, the cover image I selected for today’s post reminds of traveling this past Monday. At DFW airport, a company was giving away samples of their new variety of gum. That might have been the gum (chewed by…
Be honest, would you have seen the intentional typo in the post title if I hadn’t put it on quotation marks? It’s still not easy to see, is it? Proofreading is difficult and it’s impossible for even the skilled, dedicated…
I really don't enjoy the type of "Throwback Thursday" posts that are triggered by something in the news that reminds me of something that I've blogged about in the past.
Sometimes, it seems people are doomed to keep repeating the same preventable errors instead of learning from others, improving systems, and mistake proofing things in life. In this post, we look back at repeated errors in pathology, building demolition, and emergency alert systems...
I saw this quote the other day and tweeted it. It seemed like food for thought and something to reflect on for a new year. A Google search doesn't lead to a clear creator of this quote... it's a common thought that has been around a long time, I guess.
My guest for Episode #266 of the podcast is Karyn Ross (@KRCLean4Service on Twitter), co-author of the new book (with Jeff Liker): The Toyota Way to Service Excellence: Lean Transformation in Service Organizations.
TL;DR: Lean thinking teaches us not to blame individuals for mistakes that are caused by broken systems. In healthcare, this mindset aligns closely with Just Culture and patient safety principles: human error is inevitable, fear makes performance worse, and real…
