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.
Many of you have emailed me about this horribly sad story: “Toledo hospital nurse accidentally throws away healthy donor kidney during transplant surgery.” As a blogger, I wish I could go to the “gemba” to really help investigate and find…
To end the week, here’s a piece by our friend John Toussaint, MD, CEO of the ThedaCare Center for Healthcare Value, that was published on CNBC.com: “Don’t Kill Me! What I Want From the Healthcare System: Author of ‘Potent Medicine“…
Hat tip to my dad who saw this commercial on TV back home in Detroit. It’s an ad from the Henry Ford Health System, trumpeting their improvements in reducing errors and infections. They say if hospitals around the world adopted…
Preventable medical mistakes remain one of the most serious challenges in healthcare, yet many hospitals still struggle with learning from medical errors and preventing them from happening again. From emergency departments to pathology labs, the same types of errors continue…
The Supreme Court has mainly upheld the Patient Protection and Affordable Care Act, including the individual mandate and other controversial provisions. The court did not throw out the entire law. Congress can no longer penalize states for not expanding Medicaid…
Paul Levy, the former CEO of Boston’s Beth Israel Deaconess Medical Center, is a long time friend of mine and this blog (read his ongoing blog here although he’s no longer “Running a Hospital”). I’ve been meaning to blog about…
Last weekend, I watched a show on the Smithsonian Channel that was an interesting contrast to the CNN show I blogged about yesterday (“A Lean Guy Watches “CNN’s 25 Shocking Medical Mistakes“). The Smithsonian show was about aviation safety: “AIR…
Did anybody else see this show hosted to Elizabeth Cohen on CNN last weekend, titled “25 Shocking Medical Mistakes“? You can see a video preview or read the transcript online. I’m not sure if the whole show is available online…
Ontario’s Peterborough Regional Medical Centre is about 18 months into their Lean transformation. They are being featured in a series of four articles in their local newspaper, the first two of which are already out. Article one: LEAN machine at…
Dr. Robert Wachter has a great column in today’s USA Today: “Column: Gregory House M.D.: RIP” and it’s republished on his blog, with its own comment section. I wrote a comment, which is awaiting moderation, and I’ll repost it here….…
I had an article published in a California newspaper and it will hopefully be picked up by others. The headline is “Scared to Death: Worry about hospital errors, not pink slime.” The article starts: The public is continually subjected to…
I don’t have any first hand experience with the country, but I have had many requests for the free first chapters of my books (Lean Hospitals and Healthcare Kaizen) from Saudi Arabia over the past few years. I’m certain there…