What Didn’t Happen After This Preventable (and Potentially-Fatal) Medication…
Here is a story that was sent to me by a blog reader, who needs to remain anonymous. I know the blog reader fairly…
Browsing Tag
Just Culture
The Path to Patient Safety in Japan (or Elsewhere): Reporting Problems, Solving…
As I blogged about this morning, don't forget that you can get a FREE Kindle copy of Practicing Lean today…
What This Hospital President Said About Lean, Respecting Staff, and Just Culture
This article made me smile the other day -- especially the comments about Lean, front-line staff, and systems:
…
Are Hospitals Not Getting Any Closer to Having “Just Cultures?”
For a long time, I've been an advocate for the parallels between Lean and an approach called "Just Culture." See…
Did Bad Systems & Training, Weak Problem Solving, and Poor Supervision Cause…
The cancelation of a meaningless NFL exhibition pre-season game is probably one of the least important problems in…
Podcast #246 – Steve Montague, #Lean, Checklists & #PatientSafety
Episode #246 is my second episode in recognition of Patient Safety Awareness Week.
My guest is Steve…
Maybe We Should Call it “The Many Whys” Instead of “The Five…
There’s no magic about the number five. I’ve seen some people write that five is somehow a “magic number.” No,…
What I’m Reading: Diner Muda, No Blame at Etsy, Toyota Treats Cancer Faster,…
In case you missed it, see Saturday's post: "Why Toyota is Eliminating the Andon Cord from its Factories."
As I…
Blame: Human Error Occurs Even IF We’re Being Careful
I'm not sure why "error" was put in quotes since this seems like an actual error, not a quote-unquote error:
Staff…