Tag: Blame

Blame, Accountability, and Leadership in Lean

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.

Adverse Drug Events and Harm in Hospitals – Follow Up on...

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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...

Updated: How Often Must the Same Mistake Be Repeated?

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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...

"Heightened Vigilance" is Not Enough

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The Sun Chronicle Online - OpinionA medical error was in the news this week, a teacher was mistakenly given an insulin shot instead of...

Bad Systems in the News: Not the Worst "Oops" Possible with...

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The Lean Thinker » What Nukes?I had been mulling over trying to do a post on this story since the original story broke...

Kids Learning About Lean

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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...

Hospital Laboratory Mixups Will Happen Again, Unless…

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'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...

"An Organizational Accident"

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'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...

A History of Blame

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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...

Profile of ThedaCare’s CEO

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John Toussaint, M.D. - ProfileFrom the University of Iowa alumni site, here's a nice Q&A with one of the leading advocates for Lean in...

Bad Systems in the News: Northwest

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NWA blames pilot absences: Detroit Free PressUpdated: NWA calls back all its pilots as cancellations mountIn another example of media/management blaming, Northwest Airlines...

Bad Systems in the News: Detroit Public Schools

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I've fallen behind in my blogging the past few days, but I'll be back on track. I saw a number of news stories...

Let’s Try a "5 Whys" Survey

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Following up on the LEI survey that was released and discussed here, I've been talking with a few folks offline about what the "root...
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