Tag: Mistake-Proofing

Mistake-Proofing, Learning from Errors, and Safer Systems

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.

Error Proofing Against Drinking Bad Tap Water at #HIMSS13

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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...

A Coffee Mug Error Proofed Against Tipping?

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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...

Follow Up: American Airlines Actually Error Proofed This!

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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...

Error Proofing an NFL Coach

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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...

My Simple Keurig Mistake–and What It Teaches Us About Human Error...

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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...

Japan Tour Reflections: Taking Home Lean Artifacts or Lean Thinking?

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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...

Google’s Early Earnings Release – “Human Error” or Process Problem?

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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...

The Two Root Causes of Everything?

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One thing I have enjoyed in the past few years is meeting and working with more people with direct experience working at Toyota (including...

Learning from Medical Mistakes: Why Preventable Errors Keep Repeating in Healthcare

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Preventable medical mistakes remain one of the most serious challenges in healthcare, yet many hospitals still struggle with learning from medical errors and preventing...

I Wish American Airlines Would Error Proof This on Their Website

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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.

Moving Beyond “Be More Careful”

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Last weekend, I watched a show on the Smithsonian Channel that was an interesting contrast to the CNN show I blogged about yesterday ("A...

A Lean Guy Watches “CNN’s 25 Shocking Medical Mistakes”

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Did anybody else see this show hosted to Elizabeth Cohen on CNN last weekend, titled "25 Shocking Medical Mistakes"? You can see a video...
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