Holiday Blog Break


I'll be mostly away from the blog through January 2nd. Happy Holidays to all of you… here's a little photo treat from one of my hospital colleagues. All the Type A's were hung by the patient with care? :-)

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Here is a google translation from French to English:


    Part of the translation:

    “The nurse has admitted to mistakenly given the child an infusion of magnesium chloride instead of glucose intended to rehydrate. This misunderstanding might have caused a cardiac arrest of the child who had been hospitalized for angina.

    The nurse, aged 35, was under investigation Friday for “involuntary homicide” and placed under judicial control. It was referred to in the afternoon at the public health division of the Paris court where the judge Marie-Odile Bertella-Geffroy has held against him “a simple negligence, recklessness or carelessness.” “

    As I’ve written about before, I’m not a big fan of filing criminal charges against an individual for what’s most likely a process problem. What responsibility did hospital management and leadership have to make sure processes were error proofed so the wrong med can’t be given to the wrong patient?

    We need to focus on prevention and learning, not punishment.


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