Each week, I keep an eye out for stories that help us learn–and teach–about the systemic nature of mistakes in healthcare. Well, actually Google keeps an eye and sends me “Google Alert” email summaries with links.
I highlight cases like these not to assign blame or to disparage an industry, but to highlight what needs fixing–and is fixable. This week, two troubling incidents from India and Hong Kong reveal deeper truths about systems, safety, and the often-overlooked need for psychological safety–how safe does one feel to speak up about anything in the workplace?
Case 1: Acid Instead of Gel–A Startling Mistake in Maharashtra
In a rural hospital in Jalna, India, a pregnant woman was badly burned when hydrochloric acid was applied to her abdomen instead of medical jelly during childbirth. How does this happen?
According to reports, a sanitation worker mistakenly placed the acid on a medicine tray. A nurse, possibly overburdened or rushed, and without adequate verification protocols, picked it up and used it.
The good news? The baby was born healthy. But the mother suffered burns–and the system failed mother and nurse alike. The nurse was set up to fail by material that should never have been placed on a medication tray in the first place.
This reminds me of two stories from Toyota that I often reflect on.
David Meier, a former Toyota team member, once shared how he made a mistake during his early days on the assembly line. He installed the wrong part, and the car had to be pulled off the line. Expecting reprimand, he instead received a calm and curious response from his team leader: “Why do you think that happened?” They quickly discovered that the bins for similar-looking parts were too close together, making mix-ups easy. Instead of blaming David, the team changed the layout–fixing the system, not the person.
Similarly, Isao Yoshino, a longtime Toyota leader, told me about a young employee who made a costly error. Instead of punishment, Yoshino's mentor praised him for the courage to admit the mistake and used the moment as a teaching opportunity. At Toyota, mistakes were seen as indicators of system weakness–not personal weakness. That philosophy is foundational to their culture of learning and continuous improvement.
Both stories reinforce a powerful lesson: when someone makes a mistake, the first question should be, “What about the system allowed this?” Leaders should also ask, “What did we learn today?” That's how improvement happens. That's how trust grows. And that's how harm is prevented–not through fear, but through curiosity and support.
I hope the hospital in India had leaders who reacted similarly.
Case 2: Fallopian Tube Removed Instead of Appendix in Hong Kong
At Caritas Medical Centre in Hong Kong, a 48-year-old woman was admitted for appendicitis. A trainee surgeon mistakenly removed a Fallopian tube, misidentifying it as the appendix. The mistake wasn't discovered for five days.
This wasn't just a single person's error–it was a multi-layered failure of supervision, anatomical confirmation, escalation protocols, and quite possibly, psychological safety. One patient advocate asked the right question: “Was this surgery suitable for a doctor-in-training to perform alone?”
One person said, in response to this incident:
“To minimise similar incidents in the future, surgeons should be reminded to adhere to the basic principles of anatomy, to work within their limits and to consult their seniors early rather than late,” he said.
Feeling safe to consult their seniors, without fearing that they'll get in trouble for asking–that's also a function of culture. Are leaders and senior physicians behaving in ways that help others feel safe?
Will the system focus on learning, improvement, and prevention–or punishment?
Beyond Blame: Fixing Systems, Not Just People
It's easy–and emotionally tempting–to find someONE to blame. But if we want fewer tragedies and more learning, we need to stop asking, “Who messed up?” and start asking, “What allowed this to happen?”
Fix the system, and you fix the outcomes. That means:
- Clarifying Processes: In both cases, it seems that basic safeguards were missing. Was there a clear system for identifyijng chemicals? Was it being followed? Lean principles like error proofing and standardized work can dramatically reduce risk–if they're used.
- Improving Communication Loops: Effective teams have built-in checks, pauses, and handoffs that encourage questioning. But these only work when people feel safe to speak up. In psychologically unsafe cultures, people stay silent–and mistakes persist.
- Designing for Support: The trainee surgeon in Hong Kong wasn't inherently careless. The system that allowed them to operate without real-time supervision failed both the patient and the clinician. Oversight is not micromanagement–it's a safeguard, especially in high-risk settings.
- Reinforcing a Culture of Psychological Safety: As I've written in The Mistakes That Make Us, environments that punish mistakes stifle reporting, hide risk, and make improvement impossible. When people feel safe to say, “I'm not sure,” or “Can you double-check this with me?”–that's when real prevention begins.
Build Better Systems Before the Next Mistake
These stories aren't isolated. They're symptoms of a larger issue: healthcare systems too often default to blaming individuals instead of fixing flawed processes and unsafe cultures. We can do better–but only if we shift our focus from punishment to prevention.
Free Resource: The Mistake-Smart Leader's Checklist
If you're a leader who wants to build a culture where mistakes lead to progress–not punishment–I've created a free resource just for you:
The Mistake-Smart Leader's Checklist
This one-page guide shows you how to lead with trust, kindness, and continuous improvement. You'll get:
- 6 proven behaviors of mistake-smart leaders
- Practical prompts to use with your team
- A framework for building psychological safety
- Lessons drawn from 200+ real-world leadership stories
Great leaders don't avoid mistakes–they learn from them, fast. Let's make that the norm, not the exception.
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Let’s work together to build a culture of continuous improvement and psychological safety. If you're a leader looking to create lasting change—not just projects—I help organizations:
- Engage people at all levels in sustainable improvement
- Shift from fear of mistakes to learning from them
- Apply Lean thinking in practical, people-centered ways
Interested in coaching or a keynote talk? Let’s start a conversation.
