TL;DR: Medication and vaccine errors don’t happen because people are careless–they happen when systems make mistakes possible. This post looks at COVID vaccination examples to show why mistake-proofing, good process design, and psychological safety are essential to preventing harm in…
Eight years ago today, I published a piece originally on LinkedIn as part of their “Influencers” series: Rather than Blaming Employees, Managers Must Take Responsibility for Problems – in a Taco Joint, a Hospital, or a Factory Here is the…
Alternative headline: “Poorly Designed Card Trips Up Beatty and Dunaway at The Oscars.” Or “A Bad Process Beats Warren Beatty Every Time.” What are the Lean lessons from this mistake?
Last Thursday, I flew to Ohio after my 93-year-old grandfather was moved from the hospital to hospice. He passed away peacefully Saturday morning in the company of my dad and his three siblings. So, I have a heavy heart even…
Listen Today’s guest is my friend John Ervin and we were able to sit down together here in San Antonio to record this episode. John has about 20 years of healthcare leadership experience, including in military medicine and the civilian sector.…
In a Lean culture, the mindset is that “problems are treasure” or “problems are gold.” By honestly identifying problems, we can solve problems and prevent them from occurring in the future. Problems in healthcare can include medication errors, laboratory specimen…
Following up my post about not blaming a bartender, here’s another look at learning to cast aside our old habit of blaming individuals… this time, baseball related. Modern organizations (in healthcare and business) tend to blame an individual when something…
TL;DR: The phrase “you get what you expect and you deserve what you tolerate” appears to trace back to a 1970s Reader’s Digest article, brought into Lean and healthcare circles through Charlie Protzman’s seminars at Johnson & Johnson. I learned…
Preventable medical mistakes remain one of the most serious challenges in healthcare, yet many hospitals still struggle with learning from medical errors and preventing them from happening again. From emergency departments to pathology labs, the same types of errors continue…
Did anybody else see this show hosted to Elizabeth Cohen on CNN last weekend, titled “25 Shocking Medical Mistakes“? You can see a video preview or read the transcript online. I’m not sure if the whole show is available online…
At first I thought this post was stretching this week’s blog theme of applying Lean principles in everyday life, but I think it actually does fit quite well, at least for those of us for whom sports is a part…
Here is the second short, simple Kaizen education video from KaiNexus. You can view the first video here and the entire series. We are embedding these videos into our web-based software, to provide short tips and hints for our users. We’re also making…
