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.
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…
Retired Navy F-14 pilot and airline captain Steve “Monty” Montague spends his non-flying days helping hospitals adopt the safety culture that made commercial aviation the safest way to travel. In this episode, we talk about why standardized work frees people…
When I started blogging here in 2005, I was still about six months away from my transition from “lean manufacturing” to “lean healthcare.” It was mind boggling and disturbing to me to learn about the healthcare quality and patient safety…
Thanks to my friends at the Lean Enterprise Institute for hosting a new article of mine on their Lean Post blog. “The Question All Healthcare Leaders Should be Asking Themselves” What is that question? Click to find out. And please…
Thanks to the organizing sponsor Protegra and other sponsors, including my friends at LeanKit, for having me give a keynote talk about the Software Development and Evolution Conference (SDEC) 2013 Conference in Winnipeg yesterday (Storify summary here). I always enjoy…
Here’s an excellent commentary by Ashish K. Jha, M.D., M.P.H, a professor at the Harvard School of Public Health: “In The Race For ‘Fanciest Hospital In Town,’ Patient Safety Loses Out.” Dr. Jha argues that hospitals glad spend millions of…
