Tag: Blame
The Real #VAscandal is the Long Waiting Times & Bad Management,...
Look at the System, Not the Individuals
I've been wanting to blog about the "VA Scandal," but have avoided it because
it is somewhat politicized (as...
Blame: Human Error Occurs Even IF We’re Being Careful
I'm not sure why "error" was put in quotes since this seems like an actual error, not a quote-unquote error:
Staff 'error' blamed for chlorine...
Learning Not to Blame: Baseball Edition
Following up my post about not blaming a bartender, here's another look at learning to cast aside our old habit of blaming individuals... this...
Lean Thinking: We Don’t Blame Individuals for Systemic Errors
I saw this video last night on Paul Levy's blog and it's important enough that I want to share it here with a few...
Is it Lean’s Fault or the Old Management System’s?
It's easy for an organization to say they are "doing Lean" or they have "started a Lean transformation." They might hire a consultant or...
A Whiteboard Accident Waiting to Happen – How to Error Proof?
Yesterday, Jim Benson and I were facilitating a "Lean for Knowledge Work" class at Geekdom in San Antonio and had a great time with...
Parallels (and Differences) Between the Book “Traction” and Kaizen
When I recently did a Healthcare Kaizen workshop near Detroit, I invited an old friend of mine to attend as a guest. Marisa Smith, an...
Medical Errors: The Names Change, but the Headlines Are Sadly the...
When I started blogging here in 2005, I was still about six months away from my transition from "lean manufacturing" to "lean healthcare." It...
Learning Not to Blame: “Jerk Bartender”
In the Lean methodology, building upon the teachings of Dr. W. Edwards Deming, we work hard to shift away from "naming, blaming, and shaming."...
My Medication Error on Myself
Thankfully, it was nothing harmful or that dangerous... but I committed a medical mistake on myself last Saturday.
I tweaked my lower back last Wednesday...
Talking about Lean Healthcare in Winnipeg – #SDEC13 – and Visiting...
Thanks to the organizing sponsor Protegra and other sponsors, including my friends at LeanKit, for having me give a keynote talk about the Software...
Some Mature & Wise High School Students on Preventable Medical Errors
Near home in San Antonio, I had a chance to volunteer last Friday, speaking for an hour to a group of high school juniors...