Improving quality and safety requires more than telling people to avoid mistakes. When a problem occurs, we need to understand how the work allowed it to happen—and what could prevent the next occurrence or catch it sooner.
In The Mistakes That Make Us, I connect that responsibility with the way leaders respond to people. We need to hear about problems, and we need to do something useful with what we hear. A report followed by another reminder to be careful may leave the underlying problem untouched.
A book example: a loom that stopped itself
The book describes Sakichi Toyoda’s weaving-loom innovation: a mechanism that stopped the loom when a thread broke. The thread could still break, but the machine would not simply continue producing defective cloth.
That is a specific distinction worth bringing to a team discussion. Sometimes we can prevent the initial error. Sometimes we need to detect a problem quickly and stop it from affecting more work. In the loom example, the response was built into the equipment rather than left entirely to an operator’s vigilance.
You can read the fuller book excerpt on Toyota and mistake-proofing. The question for another workplace is not whether it needs a loom. It is where a problem can continue unnoticed, and how the process could make that problem visible sooner.
Ask where the problem becomes detectable
Take one recurring defect, missing item, or incomplete handoff. Ask the people doing the work to show you when it first becomes possible to detect the problem. Then compare that with when someone usually discovers it.
That gap can be useful to investigate. If information is missing at the start but nobody notices until the next department needs it, a check at the handoff may help. If two items are easy to confuse, changing how they are identified or stored may help. Those are possibilities to test, not solutions to impose before understanding the work.
Give people a system that helps them succeed
Another voice in the book is former Toyota leader Darril Wilburn, who describes creating a system in which people can succeed as a leadership responsibility. That puts a useful obligation on managers: involve the people doing the work in improving the conditions around it.
Training matters, but it cannot compensate for every confusing choice, interruption, or poorly designed tool. When experienced people encounter the same difficulty repeatedly, I would ask what we can change about the process before deciding they need another reminder.
That connects with looking inward instead of blaming others. A leader can take responsibility for support and system design without pretending to control every action or outcome.
Make reporting useful, then follow through
If reporting a problem leads to embarrassment, people may hesitate the next time. If it leads to no response, they may decide reporting is a waste of time. We need a constructive response and visible follow-through.
Thank the person for bringing the problem forward. Ask what happened and what made the task difficult. Agree on who will investigate, what support is needed, and when the team will hear back. Psychological safety helps the information surface; improvement work gives that information a purpose.
Check whether the change actually helped
A new checklist, alert, or device is a proposed improvement. It still needs evaluation. Did it prevent the error, detect it sooner, or create an extra burden that people work around? Ask the people using it and examine the results.
For one problem this week, try these questions: Can we prevent it? If not, can we detect it before it travels farther? What response should follow detection? How will we know whether the change helps?
The aim is to reduce the chance of recurrence and the consequences when something goes wrong. For more on testing a countermeasure and reviewing the result, see learning from mistakes with Lean.
Bring a useful conversation to your team
Start with a free preview of The Mistakes That Make Us. See how the book approaches learning, accountability, and improvement before deciding whether it is right for you.
Prefer to listen? Choose a My Favorite Mistake episode to discuss with your team. To explore these ideas together, bring Mark to your organization or event.