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.
You might remember me blogging about the Indianapolis incident where three babies died after being mistakenly given an adult dose of heparin back in 2007. The same set of failure modes led to a non-fatal overdose of actor Dennis Quaid’s…
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, to cover up is unforgivable, and to fail to learn is inexcusable.” – Sir Liam…
Lean thinkers see the waste in healthcare when they are at the hospital “gemba“. I think this is true whether you are a Lean person who is new to healthcare or if you’re a long-time hospital person who has learned…
I received an email from a reader that I’m sharing and commenting on with permission. “Dear Mark: I am a lean coordinator for a manufacturing company and it was a real shock to see some of the waste during a…
I’ve had the pleasure to work with Dr. John Toussaint, CEO of the ThedaCare Center for Healthcare Value, over the past year. John’s no “ivory tower” guy, he speaks from his practical and hard-fought experience as the CEO and Lean…
Mark’s Note: Here’s part 4 of a series by our guest blogger, Andy Wagner. Start reading with Part 1 here. “What lies behind us and what lies in front of us pales in comparison to what lies within us.” —…
Mark’s note: I consider myself very fortunate to have met Patrick Anderson during my journeys in the Lean world. Patrick is the executive director of Chugachmiut, a non-profit corporation to advance the overall economic, social and cultural development of the…
Saturday morning, as part of my preparation to cook for a brunch gathering (I really enjoy cooking as a hobby, for those who don’t know me), I took a trip to a Boston Whole Foods location. One ingredient I needed…
Here’s a thought starter for a Monday morning – I’m looking forward to hearing your perspectives. A few weeks ago, I heard a leader from a healthcare organization (one that will remain unnamed) say this: “In healthcare, we get results…
Mark’s note: It’s great to welcome Andy Wagner back to the blog. Read his older posts here. General Motors, Chrysler, and Toyota have been dominating the headlines in recent months with their financial and, now, quality troubles, while some surprising…
In recent years, healthcare has been learning a lot of lessons from aviation — including checklists and “Crew Resource Management,” as written about in the excellent books The Checklist Manifesto and Why Hospitals Should Fly. Aviation has gotten much…
TL;DR: The Olympic gold-medal puck was almost lost not because of bad intent, but because the system relied on people remembering under chaotic conditions. The real lesson is timeless: leaders must design processes that account for human fallibility instead of…
