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.
A new report from the HHS Office of Inspector General (OIG), released in July 2025, found that hospitals failed to capture 49 percent of patient harm events among hospitalized Medicare patients. The report is titled “Hospitals Did Not Capture Half…
TL;DR: Healthcare cost pressures are real, but the cost of patient harm in healthcare is far higher. Preventable events like wrong-site surgery drive massive financial losses through litigation, regulatory action, staff burnout, and reputational damage. Investing in patient safety, psychological…
“I wish moments like this didn’t seem so noteworthy. I wish focusing on safety and thanking people for speaking up was the norm in hospitals around the world.”— my comment on LinkedIn That was my response to a short yet…
This edition of Ryan McCormack’s Operational Excellence Mixtape reflects on the systems, leadership, and mindsets required for lasting improvement. From honoring Dr. Lucian Leape’s foundational work on patient safety and system-based thinking, to lessons from GE Aerospace’s Lean transformation, productivity…
TL;DR: Medical mistakes are usually system failures–not individual failures. By asking “why did this happen?” instead of “who caused it?”, healthcare organizations can strengthen psychological safety, fix broken processes, and prevent harm before it happens again. Why Medical Mistakes Are…
Recently, I had the pleasure of moderating a webinar titled “Driving a Culture of Transforming Patient Safety with KaiNexus“ featuring leaders from Our Lady of the Lake Regional Medical Center in Baton Rouge: Lindsey Booty, Dr. Christopher Thomas, and LeaAnn…
One of the most powerful elements of continuous improvement is the ability to learn from each other across organizations–even across industries. That’s one of the core reasons we host the KaiNexus Continuous Improvement webinar series. Our next live session, coming…
Scroll down for how to subscribe, transcript, and more My guest for Episode #523 of the Lean Blog Interviews Podcast is Mike Eisenberg. He’s been a filmmaker since 2010 with his production company, Tall Tale Productions, after completing his B.A.…
In 2014, The Louise Batz Patient Safety Foundation developed the Weezie’s Angel Healthcare Hero Award in honor of Louise Batz, who was lovingly called Weezie by her family, to recognize those individuals in a hospital setting who go above and…
This is a Chat GPT / Dall-E generated image: It’s silly, right? I’ve never seen a sign like this in an operating room. And I’m not advocating for them. It’s not the right approach for quality and patient safety. If…
Scroll down for how to subscribe, transcript, and more My guest for Episode #497 of the Lean Blog Interviews Podcast is Tobias Gilk, the founder of Gilk Radiology Consulting (GRC). He is an architect by training, but has spent 20+…
A nurse makes a medication error. A patient is harmed. The nurse already feels terrible — they went into healthcare to help people, and now the worst has happened. Then comes the organizational response. The investigation. The suspension. Maybe termination.…
