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January 12, 2020

"Mistake-Proofing: Designing Errors Out"


I spent a most instructive half-hour earlier this afternoon with this slim (72 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.

The book was originally published in hardcover by Productivity Press in 1995.

As of January 2002, it had been out of print for several years.

The rights reverted back to the authors, who made it available as a print-on-demand title.

Below, excerpts.

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 here.

Note: If I'd taken the road not taken and continued in academic anesthesia, eventually chairing a department, I'd have bought 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?



January 12, 2020 at 04:01 PM | Permalink | Comments (2)

Minute Repeaters Sounds Archive

Listen on the cheap: these watches can run into seven figures.

Fair warning: there goes the day.

[via Joe Peach]

January 12, 2020 at 02:01 PM | Permalink | Comments (0)

Shopping for a sponge: old ways are mos def not the best ways


Yesterday I finally got off my lazy butt and went to Kroger to buy a dish sponge.

Why'd you do that, joe?

I thought you'd never ask.

For some reason, instead of simply ordering one from Amazon a week ago when I needed one, with next day delivery, I put it on a little list of stuff I wanted to get at the grocery store, like this fantastic soda:


which as far as I have been able to determine is sold only at Kroger stores here in Podunkville.

Great stuff — but I digress.

Off I went Krogering.

I first looked for the sponge section myself but though I found every other household cleaning tool known to man, no sponges.

Then I asked two people with Kroger vests where they were: each said "Aisle 15."

That's where I'd spent 10 minutes carefully eyeing every item, without success.

So I went to the service desk and asked the manager, who replied "Aisle 15."

I told her I'd looked there but no joy, could she have someone show me the sponges?

She made a storewide public address announcement: "Associate to service desk."

Some guy appeared after five or so minutes and muttered "Aisle 15" when the manager asked him to show me the sponges, but he complied and walked there with me right behind, then pointed out the sponges.


"We don't have a big selection," he said.

Understatement: just a few 3" x 5" x 1/2" sponges sold as packs of 4.

Yo joe why'd you all of a sudden have this need for a sponge? 

Oh, yeah, I guess I buried the lede, huh?

The bottom of the copper downspout from the roof to the copper gutter right outside my bedroom window is about four feet below the level of the head of my bed, and perhaps five feet to the side of where I sleep.

There's about a 3-inch distance between the downspout and the gutter floor.

When it's raining, or when snow melts and water flows into the roof gutter and downspout, the steady drip-drip-drip of water drops on metal is loud enough to wake me up if I happen to turn over in my sleep and my good (R) ear is up (the left ear works, just not as well).

I wanted a good sized sponge, perhaps 6" x 8", to put right beneath the downspout inside the gutter to absorb the drops silently.

The sponge needed to be larger than the little ones I had, which were the same size as those in Kroger, so it didn't end up getting carried into the downspout that goes to the ground from the gutter.

I spent 10-15 minutes in Kroger on my futile pursuit.

Not to be deterred that easily, I decided to have a look at Harris Teeter's sponge selection, since it's in the same shopping center.

As I was driving over there, I realized I could've just bought a sponge from Amazon and had it in situ a week ago without all the Sturm und Drang.

Long story short: before I got to Harris Teeter, I invoked Edwin H. Land's wonderful guidance: "Solve the problem with what's in the room."

I realized I had some 6" x 9" 3M ScotchBrite scrubbing pads (below)


under my kitchen sink, where the sponges reside.

I bagged the planned H-T stop and instead headed straight home, where I proceeded to the under-sink cupboard, grabbed one of those scrubbing pads, and got up into the downspout-gutter junction and stuck a pad up into the downspout.

It was raining: instantly, the drip-drip-drip turned into silence. 


Just this one silly outing for a sponge reminded me why Amazon rules.

Going out shopping to multiple stores to try to find a particular item used to be routine: all the time and effort and frustration involved are vanished now, like tears in the rain.

January 12, 2020 at 12:01 PM | Permalink | Comments (1)

Apples of Beauty


From Atlas Obscura:

Inside a bright Brooklyn gallery is a lineup of apples assembled by William Mullan who, by publishing his fruit photographs in a book and on Instagram, is putting the glorious diversity of apples in the limelight.

Mullan, whose day job is as a brand manager for Raaka Chocolate, can rhapsodize about apples at length.

Due to the demands of industrial farming, only a handful of apple varieties make it to stores and even of those, only the most uniform specimens sit on shelves.

Growers have abandoned many delicious or beautiful varieties that have delicate skin, lower-yield trees, or greater susceptibility to disease.


Mullan was born in the U.S. but grew up in the U.K., where a teenage encounter with an Egremont Russet led to his love of apples.

Its spicy, persimmon-like flavor "just blew my mind," he says.

But many of the apples he's photographed were born in North America, including such romantic cultivars as the Black Oxford (below)


and Hidden Rose.

When health issues forced Mullan to change his diet, he satisfied his sweet tooth on apples, using the internet to research different varieties.

After moving to Southern California, Mullan entered a period of what he dryly calls "apple famine."

Only when a nearby store started carrying Pink Pearl apples (top) from Oregon was Mullan's obsession rekindled.

In the gallery Mullan, who is wearing pearl earrings, gestures to a photograph of the Pink Pearl, which, with its translucent white skin and shell-pink interior, is almost painfully beautiful.

The Pink Pearl, he explains, was bred in the 1940s by Californian Albert Etter from a red-fleshed British apple called "Surprise."

After moving to New York and wielding a camera professionally, Mullan started seeking out and photographing apples from local markets, highlighting their unique colors and shapes.


Apples are a popular crop in the Northeast, but there are more than 7,000 known varieties of apples in the world, which is an astonishing amount of diversity.

Mullan's search for rare apples has even led him to photograph varieties with no name.

After an article about Mullan’s book was published in the New York Times last year, he was invited to Geneva, New York, to visit the USDA's apple-research orchard.

There, he picked up some craggy Malus Sieversii PI 596280 apples from Uzbekistan.

Another tiny green specimen Mullan shows me is christened "Bean," after the astronaut Alan Bean, who took its seeds around the moon.

Mullan has a soft spot for Bean, especially since the USDA website describes it as small, [acidic], and "worthless."

With such a unique subject, it's perhaps no surprise that the 200 copies of Mullan's Odd Apples, a book produced with designer Andrea A. Trabucco-Campos, has sold out.

While he's still selling prints, another book is in the works.

"There's just this sense of infinity with [apples] that I love," Mullan says.

While he imagines he'll move on to other subjects in the future, for now, he's still entranced by apples.

Soon, he's slicing into a Knobbed Russet, offering me a creamy, tannic slice.

It's a little soft but after weeks on display that’s to be expected.

Without any Photoshop, a photo of a Knobbed Russet gleams gold on the wall, preserved for far longer.

January 12, 2020 at 10:01 AM | Permalink | Comments (1)

What is it?

Fooled u

Answer here this time tomorrow.

Hint: both smaller and larger than a bread box, depending on configuration.

Another: inedible.

January 12, 2020 at 08:01 AM | Permalink | Comments (0)

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