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.
I wrote about Ebola earlier this week and have been following the news closely. It’s a fascinating story on many levels, including many leadership failures. I wrote a piece for LinkedIn, written for a general public audience: A Lack of…
Mark’s Note: Today’s guest post is by Chris Burnham. I invited him to write this after I saw him share his pre-surgical “poka yoke” (or error proofing) on Twitter (caution: picture of feet). I asked him if “anybody was offended”…
Although I’m a proud alum of Northwestern University, a former marching band member, and an ardent follower of our football team (as I’ve written about before), I grew up as a fan of the Michigan Wolverines and have many friends…
In a Lean culture, the mindset is that “problems are treasure” or “problems are gold.” By honestly identifying problems, we can solve problems and prevent them from occurring in the future. Problems in healthcare can include medication errors, laboratory specimen…
I was recently interviewed by one of the reporters who put together this web article in Canada: “From the factory floor to the emergency department: Hospitals explore Lean method” The article highlights Lean success stories and it also raises some…
Chris Jerry, founder of the Emily Jerry Foundation, continues his conversation on why patient safety demands system change — not blame — and why he chose to publicly forgive the pharmacist convicted in his daughter’s death. Listen to the Episode…
I was nominated to do the ALS “Ice Bucket Challenge.” I think I was officially the last person to do so, judging from my Facebook feed. I made a donation to the ALS Association and also made this video. I’m doing…
There are certainly many serious problems in healthcare. Let’s look at nursing, in particular. It’s a rewarding job, but it’s far more frustrating for nurses than it needs to be. Nurses often don’t have enough time in the day (or…
Today’s post is a link to my article written for the LinkedIn “Influencers” series: Why Every Patient Deserves the Care & Caution that Surrounds the American Ebola Patients Please post a comment here or on LinkedIn (there’s likely to be…
We all know the beaver is “the engineer of the animal kingdom.” That’s why MIT has a beaver as a mascot… It’s an engineer who likes to build things and is generally nocturnal, an apt description of MIT students. A…
Listen: Episode #205 is a conversation with Joe Schnur, VP Business Development at Intelligent M, a company that “designs data-driven hand hygiene compliance improvement solutions for hospitals that dramatically reduce healthcare-acquired infections and their associated costs.” Joe and I share a…
I recently saw a tweet that referenced a May 2014 that was sent to President Obama and his administration: “Report to the President – Better HealthCare and Lower Costs: Accelerating Improvement Through Systems Engineering.” The report was written by the “President’s Council…
