{"id":12986,"date":"2014-01-13T05:05:28","date_gmt":"2014-01-13T10:05:28","guid":{"rendered":"https:\/\/staging.opexlearning.com\/resources\/?p=12986"},"modified":"2021-11-14T22:45:25","modified_gmt":"2021-11-15T03:45:25","slug":"a-coffee-cup-taught-me-about-poka-yoke-human-errors","status":"publish","type":"post","link":"https:\/\/staging.opexlearning.com\/resources\/a-coffee-cup-taught-me-about-poka-yoke-human-errors\/12986\/","title":{"rendered":"What a Coffee Cup Taught Me About Poka Yoke and Human Errors"},"content":{"rendered":"<div class=\"a296a24fa2fc69ef5487857f02f111e8\" data-index=\"9\" style=\"float: none; margin:10px 0 10px 0; text-align:center;\">\n<script async src=\"\/\/pagead2.googlesyndication.com\/pagead\/js\/adsbygoogle.js\"><\/script>\r\n<!-- Single Post readerboard -->\r\n<ins class=\"adsbygoogle\"\r\n     style=\"display:inline-block;width:728px;height:90px\"\r\n     data-ad-client=\"ca-pub-8207522353004717\"\r\n     data-ad-slot=\"1144967431\"><\/ins>\r\n<script>\r\n(adsbygoogle = window.adsbygoogle || []).push({});\r\n<\/script>\n<\/div>\n<p>One can learn a lot about Poka Yoke and Human Errors. This is a story about what a <a title=\"starbucks coffee and waiting time analysis\" href=\"https:\/\/staging.opexlearning.com\/resources\/starbucks-queueing-theory-constraints-lean\/7768\/\">coffee cup<\/a> taught me about how poor design in our products and systems <strong><em>invite<\/em> <\/strong>human error. Often, organizations just aren&#8217;t versed in good <a title=\"poka yoke system design principles to follow\" href=\"https:\/\/staging.opexlearning.com\/resources\/poka-yoke-system-design-how-to-mistake-proof-your-processes\/9131\/\">Poka Yoke System Design<\/a>.<\/p>\n<div align=\"center\">\r\n<table border=\"1\" cellpadding=\"5\">\r\n<tbody>\r\n<tr>\r\n<td style=\"text-align: center;\" colspan=\"2\"><strong>Other Poka-Yoke Examples and Articles<\/strong><\/td>\r\n<\/tr>\r\n<tr>\r\n<td>\r\n<ul>\r\n\t<li><a title=\"reduce what you eat with this nifty trick from facebook cafeteria\" href=\"https:\/\/staging.opexlearning.com\/resources\/poka-yoke-overeating-overweight-lose-weight\/10207\/\">Limit Food Consumption Poka Yoke<\/a><\/li>\r\n\t<li><a title=\"coffee cup has serious problems bro\" href=\"https:\/\/staging.opexlearning.com\/resources\/a-coffee-cup-taught-me-about-poka-yoke-human-errors\/12986\/\">Why This Coffee Cup has Issues<\/a><\/li>\r\n\t<li><a title=\"how to prevent errors through public humiliation\" href=\"https:\/\/staging.opexlearning.com\/resources\/poka-yoke-examples-prevent-error-embarrasment\/9511\/\">How to Prevent Errors Through Humiliation<\/a><\/li>\r\n\t<li><a title=\"can't skateboard on this park bench\" href=\"https:\/\/staging.opexlearning.com\/resources\/no-skateboarding-sign-a-poka-yoke-approach\/9448\/\">No Skateboarding Here<\/a><\/li>\r\n\t<li><a title=\"how to make sure the toilet seat cover is always down\" href=\"https:\/\/staging.opexlearning.com\/resources\/carnival-cruise-reviews-toilet-poka-yoke\/9398\/\">Toilet Seat Poka Yoke<\/a><\/li>\r\n\t<li><a title=\"atm machine creates problems\" href=\"https:\/\/staging.opexlearning.com\/resources\/to-err-is-human-atm-machine-poka-yoke\/9320\/\">This ATM Sucks and Causes Problems<\/a><\/li>\r\n\t<li><a title=\"method for checking for errors\" href=\"https:\/\/staging.opexlearning.com\/resources\/how-to-check-for-errors\/9292\/\">How to Check for Errors<\/a><\/li>\r\n\t<li><a title=\"error proof dyslexia through this font\" href=\"https:\/\/staging.opexlearning.com\/resources\/dyslexia-treatment-poka-yoke-innovation-standard-work\/9251\/\">How to Error Proof Dyslexia<\/a><\/li>\r\n<\/ul>\r\n<\/td>\r\n<td>\r\n<ul>\r\n\t<li><a title=\"error proof your baby stroller\" href=\"https:\/\/staging.opexlearning.com\/resources\/poka-yoke-baby-stroller-fail\/7242\/\">Why this Baby Stroller Will Hurt Your Child<\/a><\/li>\r\n\t<li><a title=\"door knob safety poka yoke\" href=\"https:\/\/staging.opexlearning.com\/resources\/everyday-poka-yoke-door-knob-safety\/2512\/\">Can Your Child Open the Door Knob?<\/a><\/li>\r\n\t<li><a title=\"prevent theft through this simple poka yoke\" href=\"https:\/\/staging.opexlearning.com\/resources\/everyday-poka-yoke-preventing-theft\/1993\/\">Prevent Theft Poka Yoke<\/a><\/li>\r\n\t<li><a title=\"how to prevent prescription drug abuse - one company's approach\" href=\"https:\/\/staging.opexlearning.com\/resources\/poka-yoke-pharmaceuticals\/1424\/\">Prescription Drug Abuse Error Proofing<\/a><\/li>\r\n\t<li><a title=\"zero defects via poka yoke\" href=\"https:\/\/staging.opexlearning.com\/resources\/cost-of-poor-quality-poka-yoke\/451\/\">Can Poka Yoke Help us Reach Zero Defects?<\/a><\/li>\r\n\t<li><a title=\"eye protection during war poka yoke\" href=\"https:\/\/staging.opexlearning.com\/resources\/root-cause-genchi-genbutsu-design-thinking\/439\/\">Poka Yoke Example of Eye Protection During War<\/a><\/li>\r\n\t<li><a title=\"system design poka yoke\" href=\"https:\/\/staging.opexlearning.com\/resources\/poka-yoke-system-design-how-to-mistake-proof-your-processes\/9131\/\">Poka Yoke System Design Ideas<\/a><\/li>\r\n\t<li><a title=\"be careful with that forklift\" href=\"https:\/\/staging.opexlearning.com\/resources\/forklift-and-conveyor-safety\/8484\/\">Conveyor Safety via Poka Yoke<\/a><\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<BR>\n<p>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.<\/p>\n<p>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&#8217;m not a coffee drinker. They brought him his coffee in this cup.<\/p>\n<p style=\"text-align: center;\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter  wp-image-12987\" title=\"coffee cup from ireland\" src=\"https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2014\/01\/coffe-cup-poka-yoke-shmula-abilla.jpg\" alt=\"poka yoke human errors, coffee cup from ireland\" width=\"781\" height=\"398\" srcset=\"https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2014\/01\/coffe-cup-poka-yoke-shmula-abilla.jpg 781w, https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2014\/01\/coffe-cup-poka-yoke-shmula-abilla-600x306.jpg 600w, https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2014\/01\/coffe-cup-poka-yoke-shmula-abilla-300x152.jpg 300w\" sizes=\"(max-width: 781px) 100vw, 781px\" \/><\/p>\n<p>At first glance, I thought to myself &#8220;Wow, that&#8217;s a fancy cup&#8221; because, in America, cups mainly look like, well, cups. This, on the other hand, was no ordinary cup &#8211; this was a fancy European cup.<\/p>\n<p>But, wait. Take a closer look. Do you see any problems?<\/p>\n<p>Let me tell you my friend&#8217;s experience. Perhaps you&#8217;ll see the issues as I tell you his ordeal.<\/p>\n<ul>\n<li>When my friend stirred the spoon, it hit the bumps on the inside of the cup.<\/li>\n<li>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.<\/li>\n<li>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.<\/li>\n<\/ul>\n<p>Here&#8217;s another picture to see what I mean:<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-12990\" src=\"https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2014\/01\/coffe-cup-poka-yoke-shmula-abilla-design-explained.jpg\" alt=\"coffee cup design invites human errors\" width=\"793\" height=\"688\" srcset=\"https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2014\/01\/coffe-cup-poka-yoke-shmula-abilla-design-explained.jpg 793w, https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2014\/01\/coffe-cup-poka-yoke-shmula-abilla-design-explained-600x521.jpg 600w, https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2014\/01\/coffe-cup-poka-yoke-shmula-abilla-design-explained-300x260.jpg 300w\" sizes=\"(max-width: 793px) 100vw, 793px\" \/><\/p>\n<h2>Poka Yoke, Human Errors<\/h2>\n<p>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 <strong><em>poor design and how it invites us to make errors without us even realizing it<\/em><\/strong>.<\/p>\n<h2>The System: Organization, Team, Individual<\/h2>\n<p>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.<\/p>\n<p>Back in 1999, a seminal paper entitled <sup class='footnote'><a href='#fn-12986-1' id='fnref-12986-1' onclick='return fdfootnote_show(12986)'>1<\/a><\/sup> To Err Is Human:\u00a0Building a Safer Healthcare System\u009d 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.<\/p>\n<p>This finding shook the industry and led to many patient safety initiatives thereafter.<\/p>\n<p>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 <sup class='footnote'><a href='#fn-12986-2' id='fnref-12986-2' onclick='return fdfootnote_show(12986)'>2<\/a><\/sup>. That conclusion was this:<\/p>\n<p style=\"padding-left: 30px;\"><strong>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.<\/strong><\/p>\n<p>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.<\/p>\n<h2>Back to the Coffee Cup<\/h2>\n<p>Suppose my friend burned his hand. He didn&#8217;t, but let&#8217;s suppose he spilled his coffee that morning and burned his hand. Knowing him, he would&#8217;ve blamed himself. He would called himself stupid. He would&#8217;ve felt like spilling the coffee and burning himself was all his fault.<\/p>\n<p>Would he be right?<\/p>\n<p>NO.<\/p>\n<p>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.<\/p>\n<p><a href=\"https:\/\/staging.opexlearning.com\/resources\/landing\/join-shmula\/?utm_source=sidebar&amp;utm_medium=banner&amp;utm_content=templates_page_upgrade&amp;utm_campaign=templates_page_upgrade\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-12830\" src=\"https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2013\/10\/ad-templates-page-1024x852.png\" alt=\"ad-templates-page\" width=\"819\" height=\"614\" \/><\/a><\/p>\n<div class='footnotes' id='footnotes-12986'>\n<div class='footnotedivider'><\/div>\n<ol>\n<li id='fn-12986-1'> I haven&#8217;t read the entire report, but I plan on doing so. <span class='footnotereverse'><a href='#fnref-12986-1'>&#8617;<\/a><\/span><\/li>\n<li id='fn-12986-2'> My good friend <a title=\"hi mark, it&#039;s pete.\" href=\"https:\/\/www.leanblog.org\">Mark Graban<\/a> &#8211; I&#8217;m sure &#8211; could share many stories from his work in improving healthcare. If you&#8217;re a healthcare professional, check out Mark. They guy is all about improving healthcare. I&#8217;ve learned a ton from him. <span class='footnotereverse'><a href='#fnref-12986-2'>&#8617;<\/a><\/span><\/li>\n<\/ol>\n<\/div>\n<!--CusAds0-->\n<div style=\"font-size: 0px; height: 0px; line-height: 0px; margin: 0; padding: 0; clear: both;\"><\/div>","protected":false},"excerpt":{"rendered":"<p>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&#8217;t versed in good Poka Yoke System Design. Many years ago, I had to travel to Dublin every [&hellip;]<\/p>\n","protected":false},"author":12327,"featured_media":12987,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[135],"tags":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>What a Coffee Cup Taught Me About Poka Yoke and Human Errors<\/title>\n<meta name=\"description\" content=\"Human Errors, Poka Yoke are concepts brought to life from my experience with coffee cup. This article looks into how lean six sigma can help prevent errors\" \/>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"What a Coffee Cup Taught Me About Poka Yoke and Human Errors\" \/>\n<meta property=\"og:description\" content=\"Human Errors, Poka Yoke are concepts brought to life from my experience with coffee cup. This article looks into how lean six sigma can help prevent errors\" \/>\n<meta property=\"og:url\" content=\"https:\/\/staging.opexlearning.com\/resources\/a-coffee-cup-taught-me-about-poka-yoke-human-errors\/12986\/\" \/>\n<meta property=\"og:site_name\" content=\"OpEx Learning\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/get.shmula\" \/>\n<meta property=\"article:published_time\" content=\"2014-01-13T10:05:28+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2021-11-15T03:45:25+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2014\/01\/coffe-cup-poka-yoke-shmula-abilla.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"781\" \/>\n\t<meta property=\"og:image:height\" content=\"398\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"Uday Kawar\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@shmula\" \/>\n<meta name=\"twitter:site\" content=\"@shmula\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Uday Kawar\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"4 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/staging.opexlearning.com\/resources\/a-coffee-cup-taught-me-about-poka-yoke-human-errors\/12986\/\",\"url\":\"https:\/\/staging.opexlearning.com\/resources\/a-coffee-cup-taught-me-about-poka-yoke-human-errors\/12986\/\",\"name\":\"What a Coffee Cup Taught Me About Poka Yoke and Human Errors\",\"isPartOf\":{\"@id\":\"https:\/\/staging.opexlearning.com\/resources\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\/\/staging.opexlearning.com\/resources\/a-coffee-cup-taught-me-about-poka-yoke-human-errors\/12986\/#primaryimage\"},\"image\":{\"@id\":\"https:\/\/staging.opexlearning.com\/resources\/a-coffee-cup-taught-me-about-poka-yoke-human-errors\/12986\/#primaryimage\"},\"thumbnailUrl\":\"https:\/\/staging.opexlearning.com\/resources\/wp-content\/uploads\/2014\/01\/coffe-cup-poka-yoke-shmula-abilla.jpg\",\"datePublished\":\"2014-01-13T10:05:28+00:00\",\"dateModified\":\"2021-11-15T03:45:25+00:00\",\"author\":{\"@id\":\"https:\/\/staging.opexlearning.com\/resources\/#\/schema\/person\/9335b5223b67189b35bda7d6be11c3fd\"},\"description\":\"Human Errors, Poka Yoke are concepts brought to life from my experience with coffee cup. 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