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’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…
I will try to be careful with this topic, since I’m obviously not a doctor. Criticism of doctors gets thrown around pretty easily around many hospitals, too much so, I think. You sometimes hear blanket criticisms about doctors being difficult,…
Hat tip to my friend Jack for pointing out these short videos from the Pittsburgh Regional Health Initiative (PRHI) that they call “Teachable Moments.” The first video I saw was just about 3 minutes long, perfect for YouTube and Twitter-era…
Here’s one to ponder and comment on – does putting a pharmacist in jail for six months and ruining his career and life do anything to bring back a two year-old girl? Does it do anything to make future patients…
Yesterday, I was in the first day of two for John Shook’s “Managing to Learn” class about A3 management here at the Lean Enterprise Institute. The class is based on the book of the same name. In this course, I…
On Twitter last week, Tom Peters wrote: This is the wrong premise – it’s not that doctors (and nurses, for that matter) aren’t smart or that they haven’t been taught that hand hygiene is important. The right question should be…
Thanks to my friend Amber for telling me about Dr. Atul Gawande’s interview on NPR’s Morning Edition yesterday. Regular readers of the blog will know I’m a huge fan of Gawande’s previous books Complications: A Surgeon’s Notes on an Imperfect…
