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5 – Prevent Mistakes and Look Upstream

by Jill

“By failing to prepare, you are preparing to fail.” That was a quote by Benjamin Franklin.

The other day I went grocery shopping. And right now, with the pandemic going on, I tried to go grocery shopping the least amount of time I possibly can, just to keep safe. So, I get to the grocery store, and I didn’t have a list and I didn’t really look at what I was missing or what I had in my house. And I never bought the things that I really needed to buy on that grocery shopping trip. Sure, I got about 80% of the things that I wanted, but not much more. And when I got home, I realized I didn’t have the things I really wanted. Was that a bad grocery shopping. Or was that a bad night before grocery shopping, when I didn’t even look in my fridge to see what I needed? It was definitely my failure to prepare. We see errors in our lives all the time. But we want to try to reduce them so that we can attain the goals we’re looking to get. And when I didn’t prepare to grocery shop properly, I had to go back a second time, it cost me an extra hour of time and all it would have taken was just a few minutes with my head in the refrigerator to see what I needed.


Mistake, Spill, Slip-Up, Accident, Error, Careless

This is where we get into the conversation about a pre-mortem. You’ve heard the word post-mortem, where you look at something and say “wow, what happened?” But a pre-mortem is when you look at something ahead and try to prevent the mistake in the first place. According to the Harvard Business Review, in an article from 2007 “On like a typical critiquing session in which a project team member are asked what might go wrong. The pre mortem operates on the assumption that the patient has died. So, what did go wrong? The pre-mortem seeks to identify five the threats and weaknesses via hypothetical presumption of near future failure.” It used to be Murphy’s law that said, “if anything can possibly go wrong, it does.”


This is where the concept of Poka-Yoke comes in. It’s a Japanese term, which means to basically prevent mistakes. You look at it in terms of trying to determine what will go wrong, not what has gone wrong. Some examples you can see of Poka-Yoke in our lives are things like airbags or spell checkers, fire extinguishers, nightlights, remember those Mac books that had the magnetic plugs? You can imagine that someone tripped on it just one too many times. And they wanted a way to prevent dropping your laptop on the floor and breaking it. There are two kinds of mistakes that happen. something stupid just happened. It was random and you could not have prevented it. If you want to. You were driving to work. You had every intention of getting there on time but traffic was backed up because of an accident. Can’t prepare for that. Maybe you can leave a little bit early in case it does happen. But for the most part, it happens so infrequently, that you can’t really prepare. Or mistakes that are part of the process. For example, I do laundry on Sunday night, I take my gym clothes out of my car and Friday, I wash them Sunday night, it gets late, sometimes the laundry isn’t done very early. And then I forget to put them back in the gym bag and put my gym bag back in the car. Or maybe I just forget to take the gym bag again. That’s a process mistake. Something in my process is causing things to go wrong. I made a deal with myself that I didn’t have to exercise every day after work. But if I didn’t exercise, the one thing I had to do was write down in this specific notepad, all the reasons why I didn’t exercise. The items I got from that; I forgot my gym clothes, I was too tired, I really was pretty hungry, I wanted to go home didn’t have time at the end of the day because something came up. Once I knew what was going wrong, I was able then to prevent it from happening again. I did it in a reactionary way. I reacted to a mistake I was making Poka-Yoke is about preventing the mistakes from the first place. So, whenever you start going in and start thinking about your plans, that’s where you want to try to prevent mistakes.


Upstream by Dan Heath

Upstream: The Quest to Solve Problems Before They Happen: Heath, Dan:  9781982134723: Amazon.com: Books

Dan Heath in his book upstream talks about how we can go from solving problems, but instead think ahead to preventing problems. We have to figure out what the problems are going to be. We have to figure out who the person might be that causes the process. But we also have to look at costs and benefits. You can’t have big Prevention’s for things that have little costs little problems if you don’t address them can eventually lead to big problems. Think if you never exercise because you’re always forgetting something, or always too tired it can lead to big health consequences later. By not making shopping harder, we might overspend, little things add up to big problems. His first condition is called “Tunneling”. That’s when no one sees or cares to look at the big picture, they only see their aspects of the issue, or they don’t have the resources to fix it. They suggest that you get people to stop, see the big picture, talk to other people outside their teams, then you try to work on fixing it. In software, we try to get people in complimentary teams together, all in one room, so that you can see what’s happening step by step, and then you can see the big aspects of the problem. The second issue is “Lack of Ownership”. “It’s not my problem” “I don’t benefit from the problem being solved”. Maybe in fact, “I even benefit from having the problem”. And “to be honest, I don’t really care.” When I started to exercise, I would constantly forget to put my gym clothes in the car. For a long time. I didn’t really care to solve my problem with the gym bag, because it was nice, because then I could just go home and not worry about exercising. How do you deal with that you really look at the issues and try to determine what’s going wrong, make people care about the issue and prove that it’s solvable? Maybe suggest some ideas where other people have solved similar issues that will get people excited about trying to tackle this issue or build in a reward system for overcoming apathy. You make people your helpers, if you are working with a child who keeps forgetting their backpack at home, and then you have to drive it in after they get to school, make them part of the team and have a blame free discussion. How can we get that backpack in the right spot, make them part owner of the issue, not just someone who benefits from having a problem? And then the third issue is called ‘Problem Blindness”. “Well, nothing can be done.” “It’s just how it is.” Or maybe people just don’t even think it is a problem. That’s just like, how you get people to invest in solving a problem is by showing the harm the problem causes, showing them the downstream, get them on your side by showing them why we need to solve this problem. Dan, he says “Downstream is reacting responding to symptoms, it’s easier to think about what you know, and what you’re comfortable with, than it is to think about those other things that we could do to solve a problem. Meanwhile, upstream thinking is preventative. It understands the problem and the results of the problem.

When he talks about shifting to upstream thinking compared to downstream thinking.” First of all, surround the problem. Bring in all the people who are directly involved in the problem. If it’s a child who forgets their backpack, bring the child in, maybe have a family discussion about how backpacks get to school. They can talk to the other children who maybe have succeeded in being able to bring their backpacks and come up with good ideas. Get everyone together so they can talk about the problem. The second thing is immersing yourself the problem. Dan tells us very interesting and funny story. He says “You and your friends are having a picnic by the side of the river. And suddenly you hear a shout in the direction of the water. A child is drowning, without thinking you both dive in and grab the child and swim to shore before you can recover. You hear another child cry for help you and your friend jump back into the water and rescue her as well. Then another struggling child drifts into sight. And another and another. The two of you can barely keep up. Suddenly you see your friend waiting out of the water and seemingly leaving you alone. ‘Where are you going you demand?’ your friend answers. ‘I’m going upstream to tackle the guy who’s throwing all these kids in the water’.” Just an analogy to say you can spend all of your time firefighting and solving problems. But instead, what you can do is prevent the problem from happening.

What you really want to do, he suggests is creating what you call a feedback loop. That means you can just check and see how everything is going. But try to create the system so that you can check to see if things are working. And if they’re not working find out early. He mentions that part of the problem that we have for downstream thinking is that we only reward people for solving problems. You’ll see this at workplaces all the time. People get awards for solving a really horrible problem. Maybe they fix a horrible technical issue a customer was having. Maybe the salespeople recover an angry customer who is about to cancel their contract. Rarely, the people who solve the problems ahead of time and keep the customer from getting angry, get rewarded. They’re usually forgotten. I always said when I was a server admin, the best recognition you can hope for is that everyone ignores you.



Moral Hazards

So when we think about our families do we always exclaim over the kid who finally remembers to do their homework or brings their backpack to school, and not the kid who never forgets, you don’t want to set up a situation, where people are rewarded to fail, because they’ll do it later. And they’ll start getting better at failing and start failing more and more. People learn how to game the systems, whether they’re meaning to do it or not. This is called a “moral hazard”. When you create a situation where people are rewarded for the wrong behaviors. Think of the situation when you have a workplace that gets technical support calls, and the person who answers the most number of calls gets highest rewards. We’ve created a situation where they’re getting rewarded for the most calls, not the happiest customer. So what are they going to start doing, they’re going to start answering questions quicker, and cutting the customer off. Which leads to angry customers. So really don’t set up that situation where staying in the old system is rewarded. For me, I was forgetting my gym bag. And it was a reward for me because I didn’t have to go to gym the next day.

Problem Prevention

Slip Up, Danger, Careless, Slippery, Accident, Risk

Here’s some thoughts about how you can set up a system that really helps you figure out what the problems are and start thinking about preventative matters. First of all, don’t set up a situation where people are rewarded to fail. When having discussions with your family members or whoever is having the issue that’s causing the problem? Make sure it’s a blame free discussion. Everyone feels free to answer questions about what went wrong in the process, and how they might solve it. You can try to make it impossible to error.  Could I set my gym bag in my car on Sunday nights so that I don’t forget it on Monday? Or make the mistake harder to make. Maybe my car keys sit on top of my gym bag and so I can’t drive the car until I grab the bag with it. Maybe make an early warning system, something that warns you things are not going the way you thought would. You want to do is make it very hard to make a mistake. The last thing you can try to do is to build a process that tolerates errors. That means if you make a mistake, it’s not so bad. In the end, make it simple, duplicate it, leave a note or set a reminder on one of your smart devices. Try to make it impossible to fail.

Over Preparation

Don’t get into a situation where you over prepare. It’s sometimes a form of procrastination. Prepare for the proper errors and take care of things that are likely going to happen and try your best to not overdo it. You don’t want to turn your life into such a chaotic situation where you’re preparing for every eventuality that you stop doing the important things you need to get done. Is at the end of the world if I forget my gym bag? Nope, not really. Can just put some easy things in place? Is it a hardship if your child forgets their backpack at home and you have to come home from work, get the backpack and then drive it to school? Yeah, that can be quite time consuming and leave your kid without their resources and leave you having to exit work for a couple of hours. That checklist might be bigger, because of the cost involved with having that child forget the backpack. Don’t try to prevent every mistake, try to prevent the likely ones. Otherwise, you’ll just have a headache in life, and you’ll be dealing with too many fake problems.



  1. Do a pre-mortem look into what things that you really want to have happen and try to figure out ahead of time, what might go wrong.
  2. Make sure that you don’t have tunnel vision. Make sure that you’re not just looking at your own little world but you’re looking at the bigger picture when trying to solve a problem.
  3. Make sure that the people who are involved in the problem are involved in the discussion of the solutions. Make sure that they feel comfortable in telling you what went wrong
  4. Be preventative, think upstream. Try to think of the problems and the solutions before they happen.
  5. Try to make the solutions not worse than the problem themselves.


Find one thing that seems to be consistently going wrong in your life and try to think ahead about how you can avoid those mistakes. Try to make it hard to fail. Let me know how it worked.

Fun Advice

Here’s our fun quote of the day. It comes from The Office and Dwight Schrute

“Do something ‘I think would an idiot do that?’ And if they would, I do not do that thing.”

So do you think you can prevent mistakes like that? Maybe that’s a good idea, at least is kind of a fun to think about.

Don’t forget to subscribe to the podcast. Let me know what you think of it or tell a friend. I’m happy to hear any feedback that you may have. Or if you want me to cover a particular issue for something that you’re struggling with that you’re trying to get done. You can find me and all the ways to contact me at smallstepspod.com.

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