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.
Today was an exciting day at the Institute for Healthcare Improvement‘s 21st annual National Forum on Healthcare Quality Improvement. It’s my first time here, to learn and network. They have over 5,000 attendees who are committed to quality and patient…
In Pursuit of Elegance | My Own Tiger’s Tale What does Tiger Woods have to do with Lean Thinking and hospitals? Read on… Our good friend, Matthew May, met Tiger Woods at his health club in California back in 2001.…
We had some local Boston news about hospitals reducing infection rates, including dangerous blood stream infections that result from central lines. Several academic medical centers in Boston said the number of ICU patients contracting bloodstream infections had dropped by at…
Freeport woman sues hospital after biopsy mix-up This is really discouraging to see yet another serious specimen labeling mishap in a pathology department that’s led to the good news / bad news situation that we’ve read about before: Good News:…
Episode #78 brings a very special guest, Sorrel King, to talk about systems, communication, and patient safety. Sorrel’s 18-month old daughter, Josie, was the victim of a series of preventable medical errors at a world-renowned hospital, passing away in the…
by Dan Markovitz Long-time readers of this blog (and my own) know that I focus on bringing lean techniques to individual work habits. One topic I often cover is how interruptions — from email, phone calls, colleagues — creates inefficiency…
Wachter’s World: Can Patients Help Ensure Their Own Safety? More Importantly, Why Should They Have To? The whole subject of asking patients and families to participate in safeguarding their own safety is something I’ve written about before and the idea…
Broward General nurse possibly exposed patients to risk – South Florida – MiamiHerald.com Story and nurse discussion here A number of you (thanks!) sent me this article from CNN about a Fort Lauderdale nurse who resigned — and may face…
Wachter’s World : Physician Accountability for Violation of Safety Rules: The Time For Excuses Has Passed I think Bob Wachter has it completely right in his blog post. He also makes the same point in his book Understanding Patient Safety. While…
Joint Commission Changes Requirement for Patient ID during Blood Draws | Dark Daily Thanks to my friend Robert Michel and the Dark Daily for bringing this story and issue to my attention. Definitely check out his web site if you…
Sacramento-area hospitals use simple ways to cut mistakes – Sacramento Bee This article has some great examples and an endorsement of the Lean mindset in healthcare without ever using the words “Lean” or “Toyota.” I call this the “Like Lean”…
I recently invited questions for Michael Balle, the author of the Shingo Prize winning book The Gold Mine: A Novel of Lean Turnaround. He has a new book (published by LEI, my employer), recently published, called “The Lean Manager.” Here…
