Category: Examples Blog
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Excerpts on Mistake-Proofing from “Lean Hospitals”
The following is material excerpted, adapted, and annotated from Mark Graban’s book Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. The terms “mistake-proofing” and “error-proofing” can be used interchangeably, as John Grout says… mistake and error are basically synonyms. Creating Quality at the Source through Error-Proofing Ensuring quality at the source (the Japanese word…
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Preventing a Shift Out of Park with Foot on Accelerator
Modern vehicles require the driver to put their foot on the brake pedal before shifting out of “Park.” This effectively prevents a driver from shifting into Drive or Reverse while their foot is on the gas pedal / accelerator. That’s far more effective than a warning sticker on the sun visor.
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Keurig Coffee Machine Won’t Brew without a Cup in Place
Quite often, when I’m in a hotel room, the coffee maker is a single-serving Keurig branded machine, like the one pictured above. To avoid the mess caused by a distracted traveler forgetting to put a cup or mug under the dispenser, the base where the cup goes has a sensor that can tell if even…
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A Range Finder Cam for Rock Climbing
The rock climbing equipment company, Metolius, produces this “range finder cam.” The cam anchors safety ropes into cracks in the rock. Notice the green, yellow, and red dots that run along the edge of the cam. The green dots indicate that the width of the crack is safe for use with this device. Yellow indicates…
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Ensure the Climbing Harness is Buckled Correctly
My safety harness buckle has a red mark indicating that it has not been locked (incorrect). When the buckling is complete, the red mark is covered.
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Medical Gas Connector Mistake Proofing
Medical gas outlets are designed so that the proper valves will only fit in their corresponding outlets. All of the gas valves have a pin at 12 o’clock the other pin differs in location. The second pin for medical air is at 4 o’clock.
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Preventing a Bartender from Overpouring
The devices that are attached to these bottles are liquor control systems. They insure that the right amount of liquor is dispensed for each drink It also tracks the amount so that receipts can be reconciled with inventory.
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Interoffice Envelopes – Are They Empty?
Even the lowly inter-office envelope has some mistake-proofing. In the photo at right what can you tell about the contents? First that there is something in there, second, that it is smaller than 8.5 x 11 inches, and third it’s white. Making sure a reusable envelope is empty before you send your memo can save…
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Copy Machine Door Mistake Proofing
This copy machine makes sure all the levers are in their proper position before the cover can be closed.
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Is the Record Playing at the Correct Speed?
Back before MP3’s, CD’s, cassettes, or even 8-tracks, there was an audio storage medium known as a record. Records were played on a “turntable,” as shown above. High fidelity audio required that the rate of revolution of the turntable be carefully calibrated. This was accomplished using a strobe light (shown as a red glow in the…