One can learn a lot about Poka Yoke and Human Errors. This is a story about what a coffee cup taught me about how poor design in our products and systems invite human error. Often, organizations just aren’t versed in good Poka Yoke System Design.
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Many years ago, I had to travel to Dublin every few months for work. I had team members there and part of my responsibility was to be a good leader and spend time with face to face. I was living in Salt Lake City at the time and it was a pleasure to spend time with them, even though it took me away from my family every few months or so.
One very early morning while waiting for the taxi to pick me up at my hotel to take us to the airport, my colleague with whom I was traveling with at the time had ordered coffee while I ordered a Coke since I’m not a coffee drinker. They brought him his coffee in this cup.
At first glance, I thought to myself “Wow, that’s a fancy cup” because, in America, cups mainly look like, well, cups. This, on the other hand, was no ordinary cup – this was a fancy European cup.
But, wait. Take a closer look. Do you see any problems?
Let me tell you my friend’s experience. Perhaps you’ll see the issues as I tell you his ordeal.
- When my friend stirred the spoon, it hit the bumps on the inside of the cup.
- The handle is a not really a handle that allows your fingers to securely hold the cup. Instead the handle is a ceramic stub, forcing my friend to use every muscle available in his thumb and forefinger to hold this fancy coffee cup.
- The handle has a little well, allowing the coffee to occupy the space. Coffee is hot. And, hot coffee on a handle where your thumb and forefinger is means you will burn yourself with every courageous attempt at a sip of coffee.
Here’s another picture to see what I mean:
Poka Yoke, Human Errors
For practitioners of Lean and Six Sigma, we know that Poka Yoke means error proof or designing our processes, products, and systems in a way that helps to prevent errors. But what many of us, I think, underestimate the power of poor design and how it invites us to make errors without us even realizing it.
The System: Organization, Team, Individual
Moving from a product context to a service context, design can occur at, I believe, 3 levels: the organization, the team, and the individual. Let me use a case study to explain.
Back in 1999, a seminal paper entitled 1 To Err Is Human: Building a Safer Healthcare System by Kohn, et al, examined the state of the healthcare system. The numbers the authors presented shook the industry. They reported that 44,000 people died in US hospitals every year from preventable medical errors. They estimate that number could be up to 98,000. Even at the lower estimate of 44,000, deaths from preventable medical errors were higher than the mortality rate of breast cancer and HIV/AIDS.
This finding shook the industry and led to many patient safety initiatives thereafter.
But the authors made one very significant conclusion that perhaps received the most scrutiny because it flew against the commonly held belief that human errors were due to personal recklessness and general sloppiness in the delivery of care from healthcare professionals 2. That conclusion was this:
The majority of medical errors did not result from individual recklessness, but instead were caused by faulty systems, processes, and conditions that led people to make mistakes or failed to prevent them.
In other words, pointing the finger at individuals for mistakes made is not the entire story. Perhaps we need to look into the design of the systems, processes, and the conditions that led to the errors also.
Back to the Coffee Cup
Suppose my friend burned his hand. He didn’t, but let’s suppose he spilled his coffee that morning and burned his hand. Knowing him, he would’ve blamed himself. He would called himself stupid. He would’ve felt like spilling the coffee and burning himself was all his fault.
Would he be right?
The design of our systems, processes, and the conditions that led to the event have everything to do with whether human errors are made or not. Just like looking at the poor design of the coffee cup brings insight into why coffee is easier to spill and burn the person holding the cup, looking into the design of systems, processes, and the conditions that led to the error will also bring the same insight and allow us to make longer lasting improvements that may truly prevent human errors.