Poka-yoke packaging

25 Feb 2014 4min read

Team Discussion

Multiple authors

Most people can probably think of a product that has confused or confounded them; I certainly can.  I’m always getting frustrated with products that I cannot use, they make me feel foolish and stupid and I’m neither of these things normally.

As a designer I spend a lot of time trying to make devices as easy as possible to use; in the world of medical devices, significant errors are simply unacceptable and I spend a lot of time trying to make sure that the user will feel confident and comfortable using a product. There should be no stress or anxiety, and the user must feel that they are in control at all stages. But I want to go beyond that: I don’t want the products I design to ever make someone feel foolish.

To make products ‘fool-proof’ we apply the poka-yoke principles. Poka-yoke is a Japanese term that means ‘mistake-proofing’ (originally ‘fool-proofing’) and was developed by a Toyota engineer called Shigeo Shingo – you can find out more about him here. Applying poka-yoke principles during development can help people and processes work right first time, it can drive defects out of products and substantially improve quality and reliability. It also reduces the chances of making people feel foolish.

A good example of a poka-yoke design is the:

  • shape of a phone SIM card which can only be inserted in the cell phone in the correct way.
  • network socket and plug. That guarantees correct insertion.

I’m not the only one to have spotted the value of poka-yoke; many products are developed using these principles, nevertheless some are still difficult to use, encourage misuse and lead to poor compliance. Why is this?

Maybe the product is not the problem… maybe the problem is the peripheral ‘stuff’?  Team’s approach is to regard the packaging and peripherals as an extension of the product. Everything offered to the user, all the peripherals, packaging, etc, are touch points that define the user experience and contribute to the usability of a product.

Smart companies give the same care to all product touch points, applying principles like poka-yoke to packaging and peripherals because they understand that the product is more than just the device.

Let me show you what I mean. I’ll apply the poka-yoke principles to a use scenario of a typical medical device and see what improvements we can make.

During a typical surgical procedure a range of devices are used by Surgeons, Nurses, Anaesthetists and Perfusionists. Users may be unfamiliar with the devices as they are not frequently used and/or the device may require the user to assemble several components without compromising sterility. This may lead to mistakes, anxiety, and stress; it can also make people feel foolish.

We could apply the poka-yoke principles to the packaging and peripherals to prevent mistakes from being made, or to make the mistakes obvious at a glance.  See the images of the injector pen concept that we developed for Pharmapack 2014 below.


The device’s packaging presents each of the components as required during assembly. It keeps the components separate and prevents mistakes. Components are presented in the correct assembly orientation and each step would be reinforced with instructional information at each stage, providing real-time feedback and the corrective action.

This isn’t rocket science, but for Team, the key thing we have is a focus on the user – their capabilities and how they interact with what we’ll design for them – that, and a desire to eradicate feeling foolish.

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