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.
Listen My guest for Episode #203 (and for Part 2 of our discussion in episode #207) is Chris Jerry, founder of The Emily Jerry Foundation. The foundation was created in the aftermath of the tragic death of his daughter, Emily – a preventable…
As I sometimes do, I’m going to close out a bunch of browser tabs and share some articles that caught my eye recently but don’t merit full blog posts of their own. I’m cleaning out the LeanBlog backlog and trying…
Today is the first day of the 5th annual Lean Healthcare Transformation Summit. Follow along on Twitter with hashtag #HCSummit14 to see my tweets and thoughts from others. I will be adding updates to this post during the day, as well. These are not…
Happy June, everybody! Summer is here. We’ve actually had a delightfully long spring here in San Antonio, which means the temperature hasn’t really been above 90 yet, which counts as cool (and comfortable for us). I’m headed off to Los…
Sorry to get all Katie Couric on you, but I’m going to have a colonoscopy on Friday. I turned 40 last October and I have some family history that leads my doctor to get one done now rather than at…
As a former GM employee and a GM customer, I’m really fascinated by the reaction of the public, the media, and Congress to the recalls and scandal over ignition switch problems in some GM small cars from recent years. The…
In 2009, I wrote about a nurses’ union in New Brunswick that supported Lean because they realized this methodology could help reduce waiting times and improve working conditions. It’s win Yet, as part of the recent politicized Lean healthcare brew-ha-ha in…
TL;DR: Lean thinking teaches us not to blame individuals for mistakes that are caused by broken systems. In healthcare, this mindset aligns closely with Just Culture and patient safety principles: human error is inevitable, fear makes performance worse, and real…
Since the healthcare improvement work I do is apolitical and non-partisan, I’m generally not one to butt into the political affairs of Canada or other countries. But, when I hear complaints about Lean or when it’s being called a “scam”…
Thanks to a Google News Alert email, I get news stories (on a daily basis) about hospital layoffs around the country. Many of the articles feature an executive making a reassuring sounding comment along the lines of: “Although we have…
This week is National Patient Safety Awareness Week. See my thoughts on this from 2012. Every week should be National Patient Safety IMPROVEMENT Week, as the problem is that dire. But, it’s great to try to bring to light the…
As National Patient Safety Awareness Week continues, thanks go to Graham Foster for sending me this article from the UK: Most NHS staff deem care ‘fit for their own family’. Well, that’s a positive, happy sounding headline. “Most” think the care…