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.
My friend Mike Thelen, who works in the dairy industry, has a guest post I’m going to publish next week talking about the seemingly unfounded hysteria over so-called “pink slime” that has been in the news recently. I was nauseated…
Just heard on CNN, U.S. Supreme Court Chief Justice John Roberts: “… Congress had a balanced intent. You can’t look at another provision and say this promotes patient protection without asking if it’s affordable.” Unfortunately, it seems the Chief Justice…
March 4 to 10 has been “Patient Safety Awareness Week” from the National Patient Safety Foundation. I’m certainly in favor of patient safety and have worked tirelessly, as have others, to try to improve patient safety from its abysmal starting…
This made news on Wednesday – Dr. Donald M. (Don) Berwick stepped down as CMS Administrator: “Harvard professor Don Berwick resigns as Medicare chief.” I had supported Dr. Berwick… but it didn’t really mean much because I’m not a U.S.…
The more I visit different hospitals, the more I tend to roll my eyes at the different signs that aim to remind staff and/or visitors to follow proper hand hygiene practices. These signs are often part of an arms race…
People in healthcare know that miscommunications are a major cause of errors and patient harm. There was a strange footnote to game 5 of the World Series, where the Texas Rangers beat the St. Louis Cardinals 4-2. A miscommunication led…
Hat tip to Dan Markovitz for pointing out this excellent post on John Toussaint’s blog: “The Key Leadership Behaviors in a Lean Organization?” The post is a letter written by Paul O’Neill answering a question from a hospital leader. Paul…
Some people might find this graphic inflammatory, if they are feeling defensive about the state of healthcare and if they feel like they are being blamed personally. The data in this infographic represents the current state, to the best of…
When I recently interviewed Paul O’Neill and Dr. Richard Shannon about the amazing improvements in patient safety that had been made in the Pittsburgh Regional Health Initiative organizations, they each seemed a bit frustrated that these simple, yet effective, methods…
Dr. Richard Shannon shares how Lean and Toyota-inspired methods dramatically reduced hospital-acquired infections at Allegheny General and the University of Pennsylvania. This episode explores leadership, standardized work, and why disciplined problem solving saves lives and reduces costs. Podcast #127 is…
On his blog, John Toussaint shared this letter from ThedaCare CEO Dean Gruner to all employees. Toussaint said the letter is inspired by Paul O’Neill and his thoughts on patient safety (you can hear my podcast with O’Neill here, as…
Today’s post is a case study submitted by Abdul N. Mansour, Director Lean & Process Improvement at Scottsdale (AZ) Healthcare. The material here and the PDF downloads are shared with his permission. This project is a noteworthy story in that…