Tuesday, June 19, 2007

Mistake Proofing-not 100 Proofing



My wife pointed out to me this weekend this AP article of a toddler served margarita in a sippy cup.  A restaurant kept apple juice and margarita mix in identical plastic containers and, you guessed it, the wrong bottle ended up causing the little guy to get drowsy and vomit. He’s OK now but what an ordeal. 


I read the newspaper clip to our manufacturing team this morning as an illustration of why we pay attention to mistake proofing.  I expected them to get the message. I was surprised, however, at the depth of their reaction.  Audible gasps, furrowed brows, inquisitiveness, genuine attention.  On reflection, I realized that the story has an emotional punch carrying an impact unequalled by any of my typical, more sterile manufacturing presentationsThe message was instantly recognizable and understandable. 


What I thought would be a tool for teaching about mistake-proofing turned into a deeper tool to teach me about how to teach.  The story is far more useful than the lecture.  The word picture tells more than the bullet points.  Connecting emotionally is far more important than merely transferring knowledge.  Difficult lessons for a linear-thinking engineer.  Essential lessons though.


Keep learning.  Oh, and did I tell you the one about…..?




Anonymous said...

on the other hand, the emotional charge can obscure the message.

So you have to balance
- the message,
- the story,
- the emotional charge
- the audience.

Anonymous said...

I forwarded your email out to some employees as a good story about mistake proofing...thanks for the idea!

Unfortunately, the link I pasted into my email didn't work. I guess I should practice what I preach, eh? :)

Thought you might get a laugh out of that...

Moral of the story: Sometimes it takes a story AND a real life mistake to get the point across.


Mark Graban said...

This same type of thing happens far too often in hospitals or pharmacies... wrong drug taken from identical looking packaging... people can die as a result. I'm glad the baby will be OK, we presume.