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’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…
I had a chance to attend the Lean Kanban North America conference this week. It was a different “tribe” to be a part of, as the topics focused on software and IT settings, including agile development, “kanban” project management, and…
“Approximately 8 to 10% of the individuals who walk through our doors are being hurt by us,” says David Musyj, CEO of Windsor Regional Hospital. That’s one of the first things you hear in this CBC program “Rate My Hospital,”…
Here’s the latest in my “What I’m Reading” series, where I clear out some of the inventory of articles I’ve read, but haven’t blogged about. NY crime lab improves efficiency with ‘Lean Six Sigma’ process It’s great to see Lean…
Here’s a video interview with Dr. Peter Pronovost, author of the book Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out, via AARP. It’s a brief synopsis of the patient safety…
I was fortunate to have three interviews published in the past week, where I was talking about Lean Healthcare and Kaizen, so I thought I’d share them here. Cutting Waste is More Important Than Ever: An Interview with Lean Healthcare…
In recent years, there’s been a movement away from having first-year residents work such long grueling hours – 24 hour shifts or longer, multiple days in a row on call, etc. The idea was that fatigued residents were making poor…
My guest for episode #168 is Carolyn McCulley, from CityGate Films, and she is a co-director and producer of the upcoming documentary called “Breaking the Wall of Silence,” which sheds light on patient safety challenges in healthcare — but more…