WSJ Published this cool article “Catching Deadly Drug Mistakes“.
- The picture below demonstrates a lack of understanding of the human performance model.
- We all do our best to work within the system of work, we are human and by nature make mistakes.
- Error proofing (or mistake-proofing) could help prevent this from happening.
- The idea is to make it impossible to make a mistake by design.
- The picture below depicts four vials each with a different medicine or dosage:
Sustaining Lean 