The Need to Error Proof Medication Vials, Including COVID Vaccines

Mark Graban
7 min readNov 3, 2021

I’ve given a few presentations about Lean and mass vaccination clinics, based on my visits (as a guest observer / learner and as somebody being vaccinated).

Much of what I observed (and have shared) are good practices related to patient flow and preventing delays for patients.

That relates to the first pillar of the Toyota Production System — “ Just in Time.”

There’s also a second pillar that too often gets ignored — “ Jidoka,” a word that can be translated to mean things like “quality at the source.” How do we build in quality? How do we ensure quality? How do we prevent errors?

Again, those are equally important concepts and they go hand in hand. Better flow (Just in Time) helps lead to better quality and better quality helps ensure flow is not interrupted.

I was originally going to release this blog post tomorrow morning, but I got a Moderna vaccine booster yesterday… and have been struggling through a high fever. Long story short, the pharmacy was misinformed and gave me a FULL 0.5 mL dose of vaccine, not the 0.25 mL dose.

Below is what I shared on LinkedIn. I’ll write another blog post about all of the process problems I saw at CVS before and after getting the incorrect dose injected.

Back to the original post… as I posted about last week on LinkedIn, I heard a news story on NPR about the pediatric version of the Pfizer Covid vaccine:



Mark Graban

Consultant, speaker, author, podcaster. Author @LeanHospitals & “Measures of Success.” Senior Advisor & investor @KaiNexus . Marketing @ValueCaptureLLC .