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.
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 leak at Louth’s Kenwick Park Hotel which led to five being taken to hospital When…
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 time, baseball related. Modern organizations (in healthcare and business) tend to blame an individual when something…
TL;DR: Lean thinking teaches us not to blame individuals for mistakes that are caused by broken systems. In healthcare, this mindset aligns closely with Just Culture and patient safety principles: human error is inevitable, fear makes performance worse, and real…
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 put out a press release. Maybe there’s an optimistic (but premature) news article about how the…
A simple mistake-proofing example: keep markers intended for paper away from a whiteboard, rather than relying on every person to notice the label. If two tools look similar but have different uses, changing how they are supplied or stored can…
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 entrepreneur and business owner in Ann Arbor, saw the connections between my Kaizen work and a…
When I started blogging here in 2005, I was still about six months away from my transition from “lean manufacturing” to “lean healthcare.” It was mind boggling and disturbing to me to learn about the healthcare quality and patient safety…
In the Lean methodology, building upon the teachings of Dr. W. Edwards Deming, we work hard to shift away from “naming, blaming, and shaming.” Dr. John Toussaint is one of many who provide alternatives to the “blame and shame” approach…
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 – something that, thankfully, isn’t a chronic problem (but I did just turn 40). It…
Thanks to the organizing sponsor Protegra and other sponsors, including my friends at LeanKit, for having me give a keynote talk about the Software Development and Evolution Conference (SDEC) 2013 Conference in Winnipeg yesterday (Storify summary here). I always enjoy…
Near home in San Antonio, I had a chance to volunteer last Friday, speaking for an hour to a group of high school juniors and seniors who are part of the health professions program within in the Alamo Academies program…
They just started a year ago (better late than never?), but San Francisco General Hospital had its Lean efforts highlighted in the San Francisco Chronicle last week: “S.F. General following ‘Toyota Way’ to efficiency.” On the very same day, another…
