Search Results for checklist

Lean Blog Challenge Contest Winner

Here’s the winner of the Lean Blog Challenge Contest. Congratulations to Rich, the winner of an MP3 player pre-loaded with the first 13 episodes of the Podcast. Have advice for Rich? Feel free to post your comments here. Check back…

Some Poor Problem Solving

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More travel adventures… I woke up this morning and got into the shower. I was surprised that the soap and shampoo that I used Monday morning was gone (that’s waste, throwing out half used toiletries). I stepped out of the…

Lack of CT Scan Error Proofing Leads to Death

WOAI: San Antonio News – Woman Dies after Medical Mistake at CTRC An 81 year-old woman died tragically after she was injected with 100cc of air instead of contrast die before a CT scan. The documents also state, “Found to…

How Handoffs Can Kill

Hospitals combat errors at the ‘hand-off’ I’ve blogged before about how handoffs in a process create opportunities for errors. I wrote about a trivial situation where I got the wrong muffin and Seth Godin wrote about getting the right breakfast…

Does Toyota Follow Deming’s 14 Points?

When I worked at the GM Powertrain Livonia Engine Plant in the mid-1990s, the hallway display cases held posters celebrating something called “The Livonia Philosophy.” It read, in part, like this: “through trust, communication, and respect for the individual, we…

Poor hospital processes may have killed man

MercuryNews.com | 11/02/2005 | Medical mistake may have killed man It is really sad when errors like this occur, it happens far too often in our hospitals. The newspaper headline used the non-blaming “medical mistake”, while I would prefer to…