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.
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…
As Patient Safety Awareness Week continues, thanks to all of you who shared this PBS News Hour story with me via email or Twitter. If you ever see something you think might be of interest, please let me know. On…
Today is the first of two episodes that I’ll post here during Patient Safety Awareness Week. I agree with the National Patient Safety Foundation that every day should be patient safety day. I’m sure my guest for episode #245 would…
This week is the annual Patient Safety Awareness Week. As the National Patient Safety Foundation says, “Every day is patient safety day.” I’ve expressed similar sentiments here on the blog before. I think we need more ongoing efforts to raise…
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…
