Tag: Blame

Lean Thinking: We Don’t Blame Individuals for Systemic Errors

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I saw this video last night on Paul Levy's blog and it's important enough that I want to share it here with a few...

Is it Lean’s Fault or the Old Management System’s?

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It's easy for an organization to say they are "doing Lean" or they have "started a Lean transformation." They might hire a consultant or...

A Whiteboard Accident Waiting to Happen – How to Error Proof?

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Yesterday, Jim Benson and I were facilitating a "Lean for Knowledge Work" class at Geekdom in San Antonio and had a great time with...

Parallels (and Differences) Between the Book “Traction” and Kaizen

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When I recently did a Healthcare Kaizen workshop near Detroit, I invited an old friend of mine to attend as a guest. Marisa Smith, an...

Medical Errors: The Names Change, but the Headlines Are Sadly the...

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When I started blogging here in 2005, I was still about six months away from my transition from "lean manufacturing" to "lean healthcare." It...

Learning Not to Blame: “Jerk Bartender”

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In the Lean methodology, building upon the teachings of Dr. W. Edwards Deming, we work hard to shift away from "naming, blaming, and shaming."...

My Medication Error on Myself

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Thankfully, it was nothing harmful or that dangerous... but I committed a medical mistake on myself last Saturday. I tweaked my lower back last Wednesday...

Talking about Lean Healthcare in Winnipeg – #SDEC13 – and Visiting...

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Thanks to the organizing sponsor Protegra and other sponsors, including my friends at LeanKit, for having me give a keynote talk about the Software...

Some Mature & Wise High School Students on Preventable Medical Errors

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Near home in San Antonio, I had a chance to volunteer last Friday, speaking for an hour to a group of high school juniors...

SF General Adopts Lean, Faces a Big Test with a “Never...

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They just started a year ago (better late than never?), but San Francisco General Hospital had its Lean efforts highlighted in the San Francisco...

Management Improvement Carnival #197: Lean & Deming

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Again, I'm very happy to host the Carnival for  John Hunter  and his  Curious Cat management improvement blog. My job here is to share...

Blame the Worker or the System – British Airways Engine Covers

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I flew back safely from Finland on Saturday - or I should say British Airways and American Airlines flew me safety, including in the...