Blame is often mistaken for accountability—but in practice, it creates fear, silence, and surface-level compliance. These posts examine blame through a Lean and systems-thinking lens, showing how punishment-based responses undermine learning, psychological safety, and continuous improvement.
Across healthcare, manufacturing, aviation, and leadership culture, this archive focuses less on who to fault—and more on how leaders design systems that either encourage learning or drive mistakes underground.
‘It’s never just one thing’ that leads to serious error – Los Angeles Times This is a stunning headline, it’s pretty amazing (in a good way) to find an article that doesn’t focus on blaming individuals. “It’s never just one…
If you’re a regular reader, you might recall the Cedar-Sinai medical error that harmed Dennis Quad’s twins (and others). Quaid and his wife are now suing the maker of the drug, Baxter, claiming the company is negligent for not designing…
Here are some follow-up articles, quotes, and data following up on the news from the other day that Dennis Quaid’s twins were impacted by a medication error at L.A.’s Cedar-Sinai hospital. SEE MORE POSTS ABOUT THIS CASE This article points…
Dennis Quaid’s newborns reportedly harmed by medical mix-up – Los Angeles Times (Updated 4:57 PM, again at 9:51 PM, see bottom of post) If this story sounds familiar, it’s because it is the exact same error as one that killed…
The Sun Chronicle Online – Opinion A medical error was in the news this week, a teacher was mistakenly given an insulin shot instead of a flu vaccine. Thankfully for the teacher, it’s not even something they had to be…
The Lean Thinker » What Nukes? I had been mulling over trying to do a post on this story since the original story broke in August that some nuclear-armed cruise missiles were “accidentally” or “mistakenly” moved from one base in…
SaukValley.com – Serving Dixon, Sterling & Rock Falls: Here’s a news story about career day at a High School and someone talking about Lean (I guess Wahl, the clipper company, is using Lean): “‘Poka yoke … allows you to dummy-proof…
‘I don’t want this to happen to anyone else’ This will happen again, unless the process is fixed. Lean can help. Please read on… I heard about this story this morning, this horrible tragedy where a 35-year old woman, Darrie…
‘Chicago Way’ is no way to run mass-transit system It’s something I’ve written about before, about how the media and the public tend to blame individuals, or at least we want a scapegoat. Who screwed up? Whose fault? This has…
Blame — Article by Mary Poppendieck Here’s a nice article by Mary Poppendieck, who is known for her work with Lean software development (including the book Implementing Lean Software Development: From Concept to Cash) Mary writes on the history of…
John Toussaint, M.D. – Profile From the University of Iowa alumni site, here’s a nice Q&A with one of the leading advocates for Lean in healthcare, Dr. John Toussaint, CEO of ThedaCare, which is mentioned often here on the Lean…
NWA blames pilot absences: Detroit Free Press Updated: NWA calls back all its pilots as cancellations mount In another example of media/management blaming, Northwest Airlines is blaming pilots for forcing the airline into canceling flights at the end of July.…
