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.
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…
Near home in San Antonio, I had a chance to volunteer last Friday, speaking for an hour to a group of high school juniors and seniors who are part of the health professions program within in the Alamo Academies program…
They just started a year ago (better late than never?), but San Francisco General Hospital had its Lean efforts highlighted in the San Francisco Chronicle last week: “S.F. General following ‘Toyota Way’ to efficiency.” On the very same day, another…
I recently received two emails that are worth sharing, in anonymous form here. One was from somebody I know who just quit a Lean role at a major academic medical center after a few years there, as he’s looking to…
I’ve recently heard of a scenario in healthcare that I suspect is pretty common, or at least it’s not the first time I’ve heard of this scenario. There have been stories in the news, but without naming names and without…
As we move into the Labor Day weekend, I need to close some browser tabs that are full of things that I was maybe going to write about, but don’t merit a full post. So, the latest in my “What…
