Healthcare improvement isn’t about working harder—it’s about better systems, better leadership, and a culture that supports learning and speaking up. This archive brings together blog posts, podcasts, and reflections on Lean healthcare, patient safety, quality improvement, leadership, and continuous improvement. Many of these posts draw on real hospital experiences and lessons from Deming, Toyota, and frontline healthcare teams, with a consistent emphasis on respect for people and learning from mistakes.
Tennessee regulators released an eighty-page report this week on the medication error at Ascension Saint Thomas Midtown in Nashville, where four patients scheduled for routine joint replacement were injected in the spine with potassium phosphate instead of an anesthetic. Two…
A nurse on a telemetry floor had two orders to carry out. Forty milligrams of Lasix, to be given via IV. Two units of insulin lispro, given subcutaneously. At that hospital, every dose of insulin required a second nurse to…
At Allegheny General Hospital in Pittsburgh, a nurse named Candice Bena decided a 76-year-old patient needed a new intravenous line. Radiology couldn’t install it right away. She was worried about infection, so she called Richard Shannon, who was chairman of…
Thanks, as always, to Ryan McCormack for this. He always shares so much good reading, listening, and viewing here! Subscribe to get these directly from Ryan via email. News, articles, books, podcasts, and videos about how to make the workplace…
On Thursday, I wrote about the death of Donald Gough at the University Hospital of Wales in Cardiff. He received insulin during liver surgery even though he was not diabetic and had no clinical reason to be given it. That…
A man named Donald Gough died in a Cardiff hospital in November 2022, four weeks after an insulin error during surgery. He was 77, a retired NHS radiographer who had spent more than 50 years working in the same health…
Somebody on the r/nursing subreddit asked what the worst medication error was that people had seen or heard about. Almost six hundred replies came in. I’ve read the whole thing, and there are a few ideas I want to come…
A nurse executive posted on LinkedIn this week about what she called “assembly-line medicine.” She was describing an ambulatory surgery center where she once worked, where physicians booked roughly 80 percent of the day’s procedures into a six-hour window. Then…
A close family member spent time in a hospital ICU recently. The clinical care, as far as I could tell, was excellent. The nurses were attentive. The physicians explained things clearly, and more than once. I’m grateful, and I don’t…
The target printed on the chart was zero percent. The red line had never been near zero. Not in the nine months posted on the wall, and probably not in any month before them. It sat between 6.43% and 6.98%.…
Back in 2009, I pointed an early iPhone at my TV and recorded a Fox News segment about ThedaCare’s collaborative care model. The footage is grainy. You can see the glare on the screen and hear the room around me.…
TL;DR: The NHS backlog gets narrated one month at a time, and millions in bonus money ride on the moves. A Process Behavior Chart shows most movement is noise — and the trusts that stay on top are running structurally…