Tag: Just Culture

What Didn’t Happen After This Preventable (and Potentially-Fatal) Medication Error

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Here is a story that was sent to me by a blog reader, who needs to remain anonymous. I know the blog reader fairly...

The Path to Patient Safety in Japan (or Elsewhere): Reporting Problems,...

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As I blogged about this morning, don't forget that you can get a FREE Kindle copy of Practicing Lean today (January 21, 2020). As I...

What This Hospital President Said About Lean, Respecting Staff, and Just...

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This article made me smile the other day -- especially the comments about Lean, front-line staff, and systems: Q & A with Art Gianelli, president...

Are Hospitals Not Getting Any Closer to Having “Just Cultures?”

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For a long time, I've been an advocate for the parallels between Lean and an approach called "Just Culture." See previous blog posts on this topic. Here's a good overview of Just Culture, which says, in part: "A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A just culture also recognizes that many individual or active errors represent predictable interactions between human operators and the system in which they work. However, in contrast to a culture that touts no blame as its governing principle, a just culture does not tolerate conscious disregard of clear risks to patients or gross misconduct, such as falsifying a record, performing professional duties while intoxicated, etc."

Did Bad Systems & Training, Weak Problem Solving, and Poor Supervision...

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The cancelation of a meaningless NFL exhibition pre-season game is probably one of the least important problems in the world. But, it happened recently...

Podcast #246 – Steve Montague, a Pilot’s Viewpoints on Lean Healthcare,...

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Listen: Episode #246 is my second episode in recognition of Patient Safety Awareness Week. My guest is Steve Montague, who talked about Lean and Crew Resource Management...

Rethinking the Five Whys: Introducing the ‘Many Whys’ Approach in Lean...

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There’s no magic about the number five. I’ve seen some people write that five is somehow a “magic number.” No, that’s not really the case. Ask why more than once, probably more than twice…

What I’m Reading: Diner Muda, No Blame at Etsy, Toyota Treats...

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In case you missed it, see Saturday's post: "Why Toyota is Eliminating the Andon Cord from its Factories." As I occasionally do, today's post is...

Blame: Human Error Occurs Even IF We’re Being Careful

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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...