A Florida surgeon, Thomas Shaknovsky, was indicted on a second-degree manslaughter charge on April 13. The charge followed the death of William Bryan, a 70-year-old Alabama man, during what was supposed to be a laparoscopic splenectomy in August 2024. Instead…
TL;DR: Claims that workplaces can have “too much” psychological safety are based on a flawed definition. Psychological safety doesn’t eliminate accountability–it enables speaking up, learning, and better performance. Thanks to Timothy R. Clark and Junior Clark for this excellent episode…
Here is a story that was sent to me by a blog reader, who needs to remain anonymous. I know the blog reader fairly well and believe what’s written here to be true. The blog reader is a career-long Lean…
TL;DR: Two Japanese hospitals improved patient safety by combining Toyota-style problem-solving with psychological safety. By making it safe for staff to report problems and near misses, leaders uncovered more issues, learned faster, and reduced harm–turning safety into part of daily…
TL;DR: A hospital president explains how Lean healthcare leadership, Respect for People, and Just Culture help engage frontline staff, reduce blame, and improve patient care. This article made me smile the other day — especially the comments about Lean, front-line…
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."
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 and the “comedy errors” is interesting to think about. You might notice the headline of my…
Aviation lessons for patient safety anchor this conversation with Steve Montague, a retired Navy fighter pilot and commercial airline pilot who consults with hospitals on high-reliability practices. We get into checklists done well and done badly, why most hospital mistakes…
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…
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 one where I’m going to close out some open browser tabs and post links to…
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 leak at Louth’s Kenwick Park Hotel which led to five being taken to hospital When…
