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 may know of Paul O’Neill for the dramatic employee safety improvements at aluminum maker Alcoa and you may know of him from his work in promoting healthcare improvement (he is the “bureaucrat” in “The Nun & the…
Today, I’m linking to a fantastic interview and discussion between two luminaries in the patient safety world – Dr. Robert Wachter (read his blog) and Dr. Richard Shannon (who is featured, among other places, in the “Good News: How Hospitals…
First off, there’s nothing about “Lean” per se in this linked article from Quality Digest: “New York Pediatric ICU Ward Off Central-Line Infections for Entire Year“. That said, there are elements that are very similar to both Lean and the…
Lean thinkers and TPS advocates sometimes get a bad rap as being Luddites. That’s not true, I’d say it’s more that Lean thinkers have a healthy skepticism toward technology being a “silver bullet.” You typically need good process in addition…
If you’re a regular reader of my Lean Blog, you might know more about preventing Hospital Acquired Infections than many healthcare CEOs do, says a report in the Washington Post: “Hospital infection deaths caused by ignorance and neglect, survey finds.”…
The general public still, generally speaking, doesn’t realize how much preventable harm and death occurs in healthcare each year. Efforts like the Dennis Quaid “Target Zero” TV program are trying to educate the public about how common medical harm is…
I’m blogging notes and thoughts as I watch the Discovery Channel documentary by actor Dennis Quaid and others — “Chasing Zero: Winning the War on Healthcare Harm” that first aired April 24 at 8 am EDT. With laptop and…
You might be familiar with the case where the actor Dennis Quaid’s twins were harmed by an overdose at the famed Cedar-Sinai Hospital in Los Angeles. I blogged about it originally in late 2007 as the post “How Often Must…
TL;DR: Patient safety leader Lucian Leape’s critique appears less about Lean itself and more about “L.A.M.E.”–Lean As Misguidedly Executed. True Lean in healthcare prioritizes patient safety, quality, and respect for people; when those are missing, the problem isn’t Lean–it’s how…
Here’s a thought starter for a Monday morning – I’m looking forward to hearing your perspectives. A few weeks ago, I heard a leader from a healthcare organization (one that will remain unnamed) say this: “In healthcare, we get results…
Mark’s note: I am thrilled to be able to bring you this guest post from my friend and fellow lean healthcare author Naida Grunden. Her post (and Sully’s words) are far more important than anything I could write today. Read…
In recent years, healthcare has been learning a lot of lessons from aviation — including checklists and “Crew Resource Management,” as written about in the excellent books The Checklist Manifesto and Why Hospitals Should Fly. Aviation has gotten much…