On Super Bowl Sunday in February, an 18-month-old boy was pulled from his family’s pool in Gilbert, Arizona, and rushed to Mercy Gilbert Medical Center. He was pronounced dead at 6:20 p.m. At 11:52 p.m., staff from the medical examiner’s…
Scroll down for how to subscribe, transcript, and more My guests for Episode #550 of the Lean Blog Interviews Podcast are Elisabeth Hendrickson and Joel Tosi, co-authors of the new book Signals & Levers: Systems Thinking Tools to Unblock Software…
Someone in a meeting sees a problem coming. Maybe it’s a risk in the plan, an assumption that doesn’t hold up, or a direction that doesn’t feel right. They don’t say anything. The meeting moves on, and the moment passes.…
I’m traveling internationally for ten days and I turned on one of the British news channels. There’s a major story about NHS England. First, the awful reality that a nurse would willfully kill babies in the NICU. Then, the second…
Season 2 of The Rehearsal opens in a cockpit. Two pilots are on final approach. The first officer thinks they’re lined up wrong and says so, mildly. The captain brushes it off. The first officer tries again, a little more…
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…
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 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…
On August 14, four patients went to Ascension Saint Thomas Hospital Midtown in Nashville for joint replacement surgery. All four were harmed during the procedure. The hospital has not said how. One family says the drug was potassium chloride instead…
The second revised (and expanded) edition of Timothy R. Clark’s The 4 Stages of Psychological Safety came out this week. My copy showed up yesterday, and I’ve been working through it. I’ve learned a lot from Tim over the years.…
