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.

When Steering Wheels Fly Off: Questions About Blame, Process, and Learning

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In the news yesterday, a General Motors recall over what could be just one isolated steering wheel problem in an Ohio-built Chevrolet (don't call...

An Astronaut’s Viewpoints on Systems & Patient Safety

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Today, I'm sharing a brilliant Slate.com interview: "Risky Business: James Bagian "NASA astronaut turned patient safety expert" on Being Wrong." He's actually also an...

Blog Post About Preventable Errors Felled by Preventable Error

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So Monday's blog post was about preventable medical errors - namely errors involving pharmacies giving the wrong meds or wrong doses to patients. That's...

Systems in Place to Prevent These Medication Errors? Seems Not…

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A few weeks ago, I saw a horrific story about a retail pharmacy error in the article "Pharmacy Mistakenly Gives Pregnant Woman Abortion Pill."...

Podcast #113 – Aubrey Daniels, PhD, “Safe by Accident?”

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Episode #113 is a discussion with Aubrey Daniels, PhD, the founder and chairman of his firm Aubrey Daniels International. Today, we are talking about...

10 Key Lean Mindsets for Healthcare Leaders

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I really enjoyed having the chance to be in Cincinnati yesterday to participate in a Lean Healthcare workshop put on by TechSolve, a non-profit...

Jeffrey Liker on Toyota’s Crisis, Recalls, and the Real Test of...

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Jeffrey Liker explains why Toyota's recalls were not a failure of the Toyota Way, but a breakdown in listening, speed, and customer understanding. The...

Do Good Coaches Brush Off Feedback from the Team as Whining?

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I got a question via Twitter yesterday from somebody who asked how to help production operators make the case to supervisors that their kaizen...

Reader Question: When the Stated Values Don’t Match Daily Reality

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I received a question from a reader, a retiree from a manufacturing company who is now a volunteer for a healthcare organization. We have...

Hoarders and Stashers? Ask Why…

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Short post today, but a simple message, I think. One of the best lessons I've learned about Lean management is about the need to...

Let’s Sign Documents Promising Not to Make Errors?

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You might remember me blogging about the Indianapolis incident where three babies died after being mistakenly  given an adult dose of heparin back in...

Avoiding the Risks of Using Glib Quotes in Patient Safety Discussions

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Yesterday, I tweeted a quote about patient safety that I've seen posted on the wall or bulletin board in many hospitals: "To err is human,...
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