Stuff I’m Reading, February 21, 2013: Transparent Errors, Hidden Gorillas, Gaming of Systems


Screen Shot 2013-02-20 at 8.11.47 PMIt's time again for a regular feature I call “Stuff I'm Reading.” I have too many browser tabs open and my Mac is bogging down (root cause of this?), so it's time to share some links that I may or may not blog about more fully in the future.

The president should make medical errors a priority — to save both lives and money: Paul O'Neill (hear my podcast with him) writes an open letter to President Obama encouraging him to “announce that you have ordered each of the veterans' hospitals and U.S.-based military hospitals to connect with the Internet at 8 a.m. every day to post every hospital-acquired infection, every patient fall, every medication error and every injury to a caregiver that occurred during the previous 24-hour period. Announce that this will commence March 1, and that it is your intention to require all U.S. hospitals and nursing homes to start doing this on April 15.”  O'Neill says increased transparency will lead to better safety.

4 in 10 Hospitalists Report Unsafe Patient Workloads: Health Leaders reports that “Four in 10 hospitalists responding to a survey from Johns Hopkins University say their workloads exceeded safe levels at least once a month. They acknowledged that their workload “likely contributed to patient transfers, morbidity, or even mortality.”” We can either 1) add more hospitalists or 2) reduce waste and improve processes to reduce any overburden.

Sammy Obara: Since metrics drive behavior, we want to be careful about how we establish them: “A friend of mine, ex-Geek Squad, told me BestBuy created an incentive  bonus to those store people who sold the highest number of gift cards that  month.”  Read the rest of the story… hilarity (and gaming of the system) ensues.

Why Even Radiologists Can Miss A Gorilla Hiding In Plain Sight: NPR has a story about how we tend not to see what we don't expect to see… is his true for our management “gemba walks” in addition to radiologists? It's an extension of the famous “selective attention” exercise .

State [California] lacks doctors to meet demand of national healthcare law:  “What good is it if they are going to have a health insurance card but no access to doctors?”  I was asking this years ago.

What do you think about any of those articles?

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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. I’ve used the gorilla video in classes in the past to point out the danger of not seeing the big picture in a situation. Though it only works once with the same audience, it’s an effective way to demonstrate the possibility of missing something when being too focused on a specific task.

    • It took me a few tries to see the gorilla in the radiology image! I shared that NPR piece with a pathologist friend and she got a kick out of it. Similar issues there, looking at slides…

  2. One of the keys to flight safety is full transparency of not only actual safety events but near misses and potential safety issues. I am not sure of the actual term but these safety bulletins are given high priority by pilots, mechanics, owners, and operators.

    It is almost the opposite in healthcare where we reveal and quickly bury safety events and issues. Full transparency of these issues gets my vote!


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