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April 19, 2008

'Mistake-Proofing: Designing Errors Out' — by Richard B. Chase and Douglas M. Stewart


I spent a most instructive half-hour earlier this afternoon with this slim (56 pages) book.

You know how I feel about mistakes: it's so much easier to avoid them than to correct them.

Especially if they're links in a chain of events that go off the rails as a result.

"This book was originally published in hard cover by Productivity Press in 1995. As of January 2002, it had been out of print for several years. While seeking permission to do this project, a Productivity Press representative wrote, 'The rights of this book have reverted back to the author. Please contact him directly about copyrights.' This electronic edition is published with the authors' permission."

"Prepared for distribution as an Acrobat (PDF) file and Print-on-Demand book by John Grout."

I dropped $15.97 for the dead tree version sitting here next to me; downloads cost $10.

Excerpts follow.

    Mistake-Proofing: Designing Errors Out

    This book is about mistakes and how to prevent them from ruining your business. It's about how to rescind Murphy's Law. In this book we present a way in which you can control the mistakes that cause the defects. It allows you to go back into the process, weed out the mistakes, and ensure that they will never be a problem again. We call this mistake-proofing.

    Mistake-proofing is really quality control in its strictest sense. It does not redesign a process as reengineering does, nor does it track problems as statistical process control does. It simply keeps the system performing as it was originally designed to perform.

    As a method, mistake-proofing is comprehensive. You can apply it to services just as easily as to manufacturing. This is because mistake-proofing is designed to deal with defects that originate from human mistakes as well as those that originate from equipment and materials.

    Most importantly, mistake-proofing is the only method we know that includes customers' actions in the quality control system. The importance of this is emphasized by one study that estimates that customers of services are responsible for one-third of the the problems they complain about.

    Another big advantage of mistake-proofing is that it is simple — you don't need a Ph.D. in statistics to apply it. In reality, mistake-proofing is more like a structured form of common sense.

    Mistake-proofing is also inexpensive relative to its design alternative, redundancy.

    Mistake-proofing works on the principle that if you look behind every defect, you will find a mistake that caused it. For our purposes, we define a mistake as the result of an activity, either mental or physical, that deviates from what was intended. If you can correct or prevent the mistakes in your business, you will eliminate the defects.

    Machine mistakes, being generally mechanical in nature, are better understand than human mistakes. They are, therefore, more predictable and easier to control. If we look closely at the different types of machine mistakes, we see that they fall into two categories: those mistakes we can see coming and those that catch us unaware.

    Employees experience a continuous stream of encounters — one defect is a low failure rate. Customers experience a single defect as a 100% failure rate.

    Mistakes are random events and therefore we must continuously watch for them. Sampling is not good enough. It looks at only a small proportion of the outputs in a process. It assumes that the rest of the outputs will be similar to the sample and that, therefore, we can draw conclusions about the entire output.

    The best way to ensure the detection of a mistake is to make sure that something in the environment makes it very obvious that one has been made. A good example of an environmental cue is the inevitable "extra" parts that remain after a do-it-yourself repair project. These parts make it very clear that you have not reassembled the item correctly.

    The key to creating mistake-proofing devices and procedures is not to do too much at once. Instead, concentrate on clever, inexpensive methods to check for only one mistake at a time. If you have two possible mistakes, develop two separate devices or procedures to catch them.

    Toyota, which is very experienced at mistake-proofing, averages about twelve devices for each machine.

    Go/No-Go gauges are not limited to the shop floor. Customers often use such gauges to detect and prevent mistakes. Some amusement park rides require riders to be above a certain height (so they do not slip through the safety restraints) or below a certain height (to keep larger people off of rides meant only for small children). Parks do not want customers to discover they are too small or large after waiting in a potentially very long line. By placing a gauge at he front of the line, customers can tell if they are tall enough (or short enough) to go on the ride without waiting in line.

    Remember that the goal is to develop clever, simple and inexpensive devices. Don't immediately opt for the high-tech solution.


Preview the book (table of contents and first two pages of the introduction) on the Lulu Print-on-Demand website.

Note: If I'd taken the road not taken and continued in academic anesthesia, eventually chairing a department, I'd buy as many copies of this book as there were members of my department — faculty, residents, nurse anesthetists, medical students.

Then I'd hand each person a copy as they entered weekly rounds.

The first half hour of these "Time-Out" rounds would be silent, with everyone present asked to focus on their new book.

The final half hour would be a directed free-for-all, with me leading a discussion that made its way through the book front-to-back.

What's the cost of one-brain dead patient avoided?



April 19, 2008 at 04:01 PM | Permalink | Comments (1) | TrackBack

Past Present Future Watch


"Only displays the present time, thus forcing you to focus on what is happening now."

Designed by Daniel Will-Harris.

1.25" diameter face.

Stainless steel.


April 19, 2008 at 03:01 PM | Permalink | Comments (0) | TrackBack

Tomma Abts


Her show at the New Museum of Contemporary Art in New York City is up through June 29, 2008.

Winner of the 2006 Turner Prize, the German artist, who lives in London, creates 18-7/8" x 15" — always that precise size — acrylic abstractions.


Her work has acquired cult status abroad but this is her first ever solo exhibition in New York.

The current show comprises 15 paintings made over the past 10 years.


Three of them are pictured above.

April 19, 2008 at 02:01 PM | Permalink | Comments (2) | TrackBack

Exhaust Air Jack


Most interesting and innovative.

From the website:

Exhaust Air Jack

Quickly lifts your vehicle with its own exhaust gas

Lift your vehicle in 30 seconds without straining with an awkward, unstable jack.


Simply fit the Air Jack's hose over your exhaust, position the airbag under the vehicle, and turn on your engine.

The exhaust inflates the bag, lifting the vehicle's frame 17 inches off the ground.

A one-way valve keeps the bag inflated after the engine has been turned off.


The durable Air Jack was originally designed for rugged off-road use and works in mud, snow, and on uneven ground where a regular jack cannot.

Has no negative effects on the engine.

Comes in a handy carry case to fit easily in your trunk.



April 19, 2008 at 01:01 PM | Permalink | Comments (2) | TrackBack

'Americans with PhDs beware: Telling people in Germany that you're a doctor could land you in jail'


Who knew?

Craig Whitlock and Shannon Smiley authored a Washington Post front page story about the perils of misstating one's title there; it appeared on March 14, 2008, and follows.

    Non-European PhDs In Germany Find Use Of 'Doktor' Verboten

    Americans with PhDs beware: Telling people in Germany that you're a doctor could land you in jail.

    At least seven U.S. citizens working as researchers in Germany have faced criminal probes in recent months for using the title "Dr." on their business cards, Web sites and résumés. They all hold doctoral degrees from elite universities back home.

    Under a little-known Nazi-era law, only people who earn PhDs or medical degrees in Germany are allowed to use "Dr." as a courtesy title.

    The law was modified in 2001 to extend the privilege to degree-holders from any country in the European Union. But docs from the United States and anywhere else outside Europe are still forbidden to use the honorific. Violators can face a year behind bars.

    Ian Thomas Baldwin, a Cornell-educated researcher at the Max Planck Institute for Chemical Ecology in Jena, has stopped calling himself "Dr." ever since he was summoned for interrogation by police two months ago on suspicion of "title abuse."

    "Coming from the States, I had assumed that when you get a letter from the criminal police, you've either murdered someone or embezzled something or done something serious," said Baldwin, a molecular ecologist. "It is absurd. It's totally absurd."

    No one has questioned the legitimacy of his degree or whether he has the right to conduct research here. But going by "Dr." is verboten. If he wants to refer to his doctorate, German law dictates that he identify himself as "Prof. Ian Thomas Baldwin, PhD, Cornell University."

    Baldwin confessed in a telephone interview that "there's no question I'm guilty as charged." But he hopes prosecutors will give him a break.

    In his defense, he noted that the Max Planck Institute has always addressed him as "Prof. Dr. Baldwin" since it offered him a job a decade ago, and nobody warned him he might be in legal peril if he did likewise.

    The proper use of honorifics is no small matter in Germany, a society given to formality where even longtime neighbors insist on addressing each other using their surnames. Those with advanced degrees like to show them off, and it is not uncommon to earn more than one. A male faculty member with two PhDs can fully expect to be called "Herr Professor Dr. Dr. Schmidt," for example.

    In effect, forcing Americans to forsake their titles amounts to a social demotion. "It's an indication of the hierarchization of German society," said Gary Smith, director of the American Academy in Berlin. "Germans are much more status-conscious about these things, and the status is real."

    Smith holds a doctorate from Boston University and has tempted fate by answering to "Dr. Smith" during the two decades he's lived in Germany. He said he was told years ago that there is a legal way for foreign PhDs and MDs to register for permission to use the appellation, but he has never bothered.

    "It wasn't worth the trouble of doing anything about it," he said. "It's really an absurd situation in a globalized world."

    The German doctor rule has been in effect since the 1930s, but it has been only sporadically enforced in recent years.

    That changed last fall, when an anonymous tipster filed a complaint with federal prosecutors against seven Americans at the prestigious Max Planck Society, which operates 80 scientific research institutes across Germany. Federal authorities forwarded the complaint to prosecutors and police in at least three states, who decided to take action.

    Joerg Stolz, the chief prosecutor in the city of Jena, which is investigating Baldwin and another researcher at the Max Planck Institute there on suspicion of title abuse, said those two probes were "near closure."

    He said his office had recommended to a judge against filing charges. In that event, he said, the matter would be referred to the Cultural Ministry in the state of Thuringia, which could still decide whether a civil fine is warranted.

    Detlef Baer, a spokesman for the ministry, said officials planned to drop both cases. "We spoke with the parties involved and determined they had no criminal intent," he said. "They were given instructions as to how they can refer to their titles," by citing the degree but not calling themselves doctors.

    Another American investigated by police is an astrophysicist with a doctorate from Caltech and membership in the German Academy of Sciences.

    The criminal investigations have alarmed higher education officials in Germany, where U.S. researchers are in high demand and treated as blue-chip recruits. Last week, state education ministers met in Berlin and recommended that the law be modified so anyone holding a doctorate or medical degree from America could be addressed as "Dr." without running afoul of the police.

    "This is a completely overdone, mad, absolutely ridiculous situation," said Barbara Buchal-Hoever, head of Germany's central office for foreign education. "We are talking about highly acclaimed researchers here.... The people who have pressed charges must be gripers or troublemakers who wanted to make a totally absurd point."

    Even if the proposal is adopted, however, it would extend the privilege only to people with degrees from about 200 U.S. universities accredited by the Carnegie Foundation for the Advancement of Teaching. Anyone with a PhD from Canada, Japan or the rest of the non-European world would still be excluded.

    For now, the old law remains on the books. It is unclear when, or if, Germany's state parliaments will change it.

    So the next time Dr. Condoleezza Rice (PhD, University of Denver) or even German-born Dr. Henry Kissinger (PhD, Harvard) pay a visit to Berlin, they may want to stick with the title "secretary of state."

April 19, 2008 at 12:01 PM | Permalink | Comments (1) | TrackBack

World's smallest dynamo flashlight


From the website:

    Mini Dynamo Crank — World's smallest dynamo flashlight

    Who says dynamo flashlights have to be big, bulky and ugly?

    This sleek little piece measures just 1.9" x 3.1" x 1" yet packs a powerful hand crank dynamo and three super bright LED lights.

    The perfect size for a glovebox, purse, or kitchen drawer.

    Will never need batteries or replacement bulbs.

    Rubberized comfort grip with tether strap.


Pink, Green or Black.


April 19, 2008 at 11:01 AM | Permalink | Comments (1) | TrackBack

TechnoDolt™ kludge to improve your Wi-Fi experience


From time to time I note that the little icon at the top of my laptop screen indicating Wi-Fi signal strength shows only two dark thingies instead of the usual full Monty four.

The only time I look is when for some reason the Internet seems to have slowed down or stopped, in terms of pages loading.

Turns out that simply restarting my trusty PowerBook (now well into year four of our happy coexistence, still chugging along with Panther 10.3.9 without any problems whatsoever — current speeds are shown up top) invariably results in at least three thingies.

Who knew improving Wi-Fi signal strength could be so easy?

Now that's how TechnoDolts™ do it.

April 19, 2008 at 10:01 AM | Permalink | Comments (1) | TrackBack

Shoeshine Wall Bracket


From the website:

    Shoeshine Wall Bracket

    Our Shoeshine Wall Bracket elevates shoes and frees hands for an easy, professional shine — with no mess.

    Simply screw mounting base onto wall at desired height.

    Lightweight aluminum bracket slides into base and removes when finished.

    Bracket adjusts for men's or women's shoes to size 13.


$21.95 (shoe not included. Prolly the wrong size, anyway. Besides, even if it fits you're still one shoe short, what?).

April 19, 2008 at 09:01 AM | Permalink | Comments (0) | TrackBack

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