In 2006, regulators cited a hospital in Madison, Wisconsin for six violations of state and federal rules after a patient died — three federal, three state. They threatened its license and its Medicare contract. The hospital updated its policies and…
Hospitals have Quiet Rooms now. There’s soft lighting. There’s a chair. There’s a noise machine, which is a machine that makes calming noises. There’s sometimes a succulent in a small white pot. The succulent is doing fine, which makes sense,…
Phoebe Wall Howard reported recently that a fired GM engineer is suing the company over its employee evaluation system. Tuan Le, 58, spent 27 years at General Motors, moving from industrial engineer to senior throughput simulation engineer. GM terminated him…
For three weeks after his surgery, a patient at the Royal Oldham Hospital (England) had no bowel movement and was in increasing pain. The ward sister kept raising patient safety concerns with the surgeon who’d operated on him. She described…
Twice in the past two weeks, I have talked with people who want to write a book about Lean. Both were early in the process and trying to figure out what they were signing up for. I’ve had a lot…
In early 2025, Eric Veiel asked Larry Culp a question that most Lean deployment articles skip: when you’re getting ready to implement one of these programs, is there some hesitation from the workforce? Culp didn’t argue with the premise. “Well,…
You came back with real energy. You’d seen how the work could be. You had notes, a few ideas, maybe a plan you’d already started sketching on the drive home. Then you walked back into the same building, run by…
Tennessee regulators released an eighty-page report this week on the medication error at Ascension Saint Thomas Midtown in Nashville, where four patients scheduled for routine joint replacement were injected in the spine with potassium phosphate instead of an anesthetic. Two…
A nurse on a telemetry floor had two orders to carry out. Forty milligrams of Lasix, to be given via IV. Two units of insulin lispro, given subcutaneously. At that hospital, every dose of insulin required a second nurse to…
At Allegheny General Hospital in Pittsburgh, a nurse named Candice Bena decided a 76-year-old patient needed a new intravenous line. Radiology couldn’t install it right away. She was worried about infection, so she called Richard Shannon, who was chairman of…
I’ve been rereading Takehiko Harada’s book Management Lessons from Taiichi Ohno. Harada joined Toyota Motor Corporation in 1968 and spent about four decades there, including time as project general manager of the Operations Management Consulting Division, the group Toyota used…
I’ve been photographing warning signs for years. It started as a running joke and turned into a whole category on my site. Signs that say “Be Careful.” Signs that say “Do Not Spill.” Signs that exist because something went wrong…