Mistakes are inevitable—but how leaders and organizations respond to them determines whether they improve or repeat the same failures. These posts explore mistakes through a Lean lens: system design vs. “human error,” psychological safety, learning cultures, and leadership behaviors that turn errors into improvement rather than blame.
Drawing from healthcare, manufacturing, aviation, sports, and everyday work, this archive focuses less on who failed—and more on what the system made possible.
Mistakes are inevitable; learning is not. These posts align with ideas I expanded on in The Mistakes That Make Us, which examines how leaders, cultures, and systems determine whether errors become liabilities—or catalysts for improvement.
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…
Someone walks into your office and says, “We have a problem.” Notice what your body does before your brain catches up. A small tightening. A breath you take to steady yourself. Maybe your face does something you didn’t authorize. All…
I was reading The Birth of Lean, the Lean Enterprise Institute’s collection of interviews with the people who built the Toyota Production System, and one answer from Eiji Toyoda is worth quoting in full. This is Eiji Toyoda on mistakes,…
“Challengers” A college friend of mine sent me a photo from Oslo recently. He’d spotted a display about IKEA founder Ingvar Kamprad and his “challengers” just outside the Nobel Peace Prize Center and the National Museum, and sent the translation…
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…
At the 2024 KaiNexicon (the KaiNexus user conference), I gave a talk called “Warning: Signs! From Cautionary Commands to Proactive Prevention” — a tour through the world of warning signs, why they don’t work very well, and what we can…
Last week, Anthropic accidentally leaked nearly 2,000 internal source code files for Claude Code, their AI coding tool. Within hours, the code was copied across the internet. A post sharing a link to it got 29 million views. Anthropic called…
If you’ve used ChatGPT, you’ve seen the small text at the bottom of the screen: “ChatGPT can make mistakes. Check important info.” I noticed it again the other day and thought (and wrote on LinkedIn) — I need the same…
TL;DR: NUMMI proved in the 1980s what healthcare is still learning today: you can’t punish your way to safety. Real improvement comes from mutual trust, system thinking, and leaders who respond to problems with curiosity–not blame. When we talk about…
Ray Zinn argues that effective leadership isn’t about failing fast, but about learning from mistakes by acknowledging them quickly, fixing them early, and not repeating what already doesn’t work. I recently had the pleasure of hosting Ray Zinn on the…
This edition of Ryan McCormack’s Operational Excellence Mixtape highlights practical thinking on value creation, continuous improvement, and leadership in an AI-influenced world. From empowering nurses at Cleveland Clinic and using AI as a problem-solving coach to avoiding common change mistakes…
At the hospital on Monday, a chaplain shared a Thanksgiving poem on the theme of being grateful.
It struck a chord with me. As a Lean practitioner, it's easy to focus on the waste... the problems... the gaps. We think about what could be and the "ideal state." We strive for perfection and it's easy to lose site of what we have.
