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.
I’m traveling internationally for ten days and I turned on one of the British news channels. There’s a major story about NHS England. First, the awful reality that a nurse would willfully kill babies in the NICU. Then, the second…
In 2006, regulators cited a hospital in Madison, Wisconsin for six violations of state and federal rules after a patient died — three federal, three state. They threatened its license and its Medicare contract. The hospital updated its policies and…
Hospitals have Quiet Rooms now. There’s soft lighting. There’s a chair. There’s a noise machine, which is a machine that makes calming noises. There’s sometimes a succulent in a small white pot. The succulent is doing fine, which makes sense,…
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…
For three weeks after his surgery, a patient at the Royal Oldham Hospital (England) had no bowel movement and was in increasing pain. The ward sister kept raising patient safety concerns with the surgeon who’d operated on him. She described…
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…