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.
Each Saturday, I get an email newsletter from the UK-based site "Nursing Times." Last week, this article, caught my eye: "Workplace principles revealed for NHS staff in Wales." A free registration might be required to read it or other articles, but it's worth it.
My guest for episode #240 is somebody I’ve wanted to interview for a long time, Leah Binder, the president and CEO of Leapfrog Group, “a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big…
Later today and tomorrow, I’ll be attending the annual World Patient Safety, Science & Technology Summit that’s produced by a non-profit called the Patient Safety Movement. If you’re also at the event, please say hi! Follow the event on the…
As we start easing into the holidays, I wanted to share a few throwback posts from this day or this week from previous years: From this date in 2009: The Emperor’s Sacred Cow’s New Clothes – “Flexing” Hospital Staff I’d…
Here's a "Throwback Thursday" post from this date back in 2008. The post is titled, "Why Do Hospitals Have to Rely on Vigilant Patients and Families?" I think it's still an important and relevant post, here in 2015. Why do we ask patients and families to be vigilant and inspect the work being done...
It's tempting to visit a place like ThedaCare and then mandate "everybody must have huddle boards." Then, a bunch of huddle boards get purchased and installed... and maybe not used. It's another thing for executives to realize that they have to change the way they manage. There's a great quote that ThedaCare folks readily share, including Kim Barnas in her book Beyond Heroes:
In healthcare, it’s a well-known problem that people often don’t speak up to point out risks or to report near misses. It’s an organizational culture problem… people are afraid of being blamed, punished, or retaliated against for speaking up. A…
tl;dr: A sushi company’s safety and quality policy illustrates what hospital operational excellence really requires: visible leadership commitment, daily practice, and systems that make safety the default–not a slogan. I love the Texas-based grocery store chain “Central Market.” It’s basically…
As I wrote about last month, I love newspapers, so I felt like I fit into the culture last week when I spent five days of my vacation in London, a city I really love. People in England seem to…
Wednesday was the first day of the 6th annual Lean Healthcare Transformation Summit, being held this year in Addison (Dallas), Texas. I’m here and this year my colleagues Dr. Greg Jacobson and Jeff Roussel from KaiNexus are attending, so please say hi…
There’s been a back-and-forth of views about the state of pediatric emergency medicine recently in the Wall Street Journal. Let me start first, actually, with the more recent statement, a rebuttal from Michael Gerardi M.D., FACEP, President of the American College of Emergency…
Following up on yesterday’s post on seemingly successful experiments with ACOs, here’s another article, from HBR, on “safety huddles” in healthcare: “How Every Hospital Should Start the Day“ I’ve seen some hospitals using daily safety huddles. It sends a powerful message…