Patient safety doesn’t improve through punishment, vigilance posters, or telling people to “be more careful.” It improves when leaders design safer systems, support speaking up, and focus on learning instead of blame. This archive brings together blog posts, podcasts, and reflections on patient safety through a Lean lens—exploring medical errors, near misses, psychological safety, leadership behaviors, and how healthcare organizations can reduce harm by fixing systems rather than blaming individuals.
It's great to see Lean healthcare featured in one of the world's leading news and business publications. The Economist recently published this article:
"Hospitals are learning from industry how to cut medical errors"
I'll be teaching my "Better Metrics" workshop (aka "Measures of Success," ala my book) twice in June:
Cambridge Investments - Open for Public Registration (Fairfield, Iowa) -- June 5
Lean Healthcare Transformation Summit (Chicago) -- June 13
After facilitating the Red Bead Experiment in the workshop, one other way I've found to simulate variation is an online simulation that's available, of all places, on the BBC website:
"Can chance make you a killer?"
Healthcare is full of terms that obfuscate things. Ironically, use of the word "obfuscate" can be an example of obfuscation.
Instead of saying, "Healthcare leaders often obfuscate a situation," we can say, "The language used in healthcare often makes things sound better or more complicated than they really are."
TL;DR: Captain “Sully” Sullenberger’s leadership lessons from Flight 1549 highlight that safety depends on humility, trust, teamwork, and learning from mistakes–not heroics or checklists alone. High-risk industries like aviation improve safety by focusing on systems, psychological safety, and fact-based decisions.…
Today's post is my eighth cartoon collaboration with a skilled artist and medical assistant, Carrie Schurman (see past cartoons). You can find her on Twitter as @carrieschurman.
Today is a day known as "Giving Tuesday," to follow up the commercially-driven "Black Friday" and "Cyber Monday" days.
It's a great day to give to any cause or organization that's meaningful to you.
One organization that I choose to give to throughout the year is the Louise H. Batz Patient Safety Foundation. The Batz Foundation produces practical and helpful guidebooks and apps to help protect patients during their hospital stay or other healthcare encounters.
I recently saw a presentation by some leaders from a children’s hospital. I was really impressed that their medical quality and effectiveness leaders were outspoken advocates for Lean and Six Sigma, as was their director of process improvement. They shared…
TL;DR: A 1966 magazine exposé documented widespread, preventable patient harm caused by system failures in American hospitals. While some areas have improved, many of the same problems–errors, infections, lack of transparency, and blame instead of learning–still persist today. Three or…
If this post is a bit of a rant, I apologize. The problems here are avoidable and fixable. That’s one reason I get so fired up about patient safety. Patient harm is not an unavoidable natural disaster, like a hurricane.…
"Through a collaboration with Toyota, Children's HealthSM, the leading pediatric health system in North Texas, announced today it has successfully reduced rates of central line-associated blood stream infections (CLABSIs) by 75 percent with patients in the gastroenterology unit."
I'm excited to be playing host for a KaiNexus webinar on August 30 on a topic that's very important to me (and to many) -- patient safety.
As I mentioned yesterday on LinkedIn, estimates suggest that medical error is the third leading cause of death in the United States, with approximately 250,000 deaths a year... and that's four times as many deaths as caused by the opioid crisis.
Don't get me wrong, opioid abuse and what happens to patients who end up addicted is horrible. But the newly-named "national emergency" of opioid abuse gets far more attention than what I would call "the international patient safety emergency" that has been around for a long time.
I try bringing attention to the serious, yet solvable, problem of patient harm caused by preventable medical error. That's why I'm happy that we'll have three presenters on the 30th on this topic:
"Teaming with Patients to Improve Safety"
Click here to register - the webinar is free.
A few of you sent me this sad article from the Wall St. Journal:
"'People Are Dying Here': Federal Hospitals Fail Tribes."
I feel like I've some variation of this article and exposé many times over. Sometimes, it's some form of government medicine (active duty military medicine, the VA, or another country) or it's a similar sad story from the private healthcare sector (be it non-profit or for-profit).