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.
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…
Following up on my previous posts (here and here) on a recent visit to the Northern California Wine Country, I’m going to share a few more ideas and thoughts based on what I saw during the trip (when I wasn’t…
In hospitals, there’s a big emphasis on healthcare professionals always checking TWO patient identifiers to help avoid getting the wrong patient. You might have two patients with the same name, so you should also check the birth date (since it’s…
I’ve been writing for a long time that I think it’s inappropriate and ineffective to ask patients and families to inspect or police hand hygiene in hospital settings. It’s the job of healthcare leaders to create systems that include enough…
QHSE Focus, an iPad magazine, asked me to contribute a piece on Lean healthcare. They published my piece titled, “Employee & Patient Safety: The Only Moral Place to Start with Lean in Healthcare.” You can read a PDF of the…
I was happy to see that one of my local Indian restaurants not only has very good Yelp reviews… they also have a top score (a perfect score!) from the health inspector. This is proudly displayed (as it should be)…
A woman has the wrong side of her brain operated on. The headline features the hospital’s name and the surgeon’s name. It seems the “name, blame, and shame” process has begun. SSM Health Care St. Louis, Dr. Armond Levy face…
This week, May 6-13, is National Nurses Week. It’s always important, but it’s especially good to thank and recognize all of the talented, caring, hard working nurses out there. Nursing is important, difficult work. Sadly, the work is made more…
