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.
Ledger-Enquirer | 03/27/2007 | Campaign’s goal is to reduce infections To those who might have thought I overstated the situation with hand washing in hospitals, here’s another article about maintaining proper hygiene among hospital staff and caregivers. One particular risk…
The Blotter: ABC Report on Pharmacy Errors I first stumbled across this 20/20 report when I saw a preview on the ABC investigative reports video podcast. Pharmacy errors are a major problem (see this story): There are as many as…
StuderGroup – Conversations with Quint Studer Another great discussion from Quint Studer’s management blog (I hate to call it a “healthcare blog” because that might keep you manufacturing leaders away). Here is a direct link to a post called “What…
Kevin, M.D. – Medical Weblog: A woman dies after receiving 8 grams of Dilantin I read about this on the blog linked above and the source article is here. A nurse administered an incorrect dose to a patient, TEN TIMES…
A Novel Plan Helps Hospital Wean Itself Off Pricey Tests – WSJ.com Kevin, over at Evolving Excellence, raised a similar issue about misaligned incentives and misleading metrics in healthcare (thanks for the mention, Kevin). This article, linked above, from the…
In the news: Charges against nurse igniting a debate This case — involving Wisconsin nurse Julie Thao — is still referenced in debates about whether medical professionals should face criminal charges for unintentional errors. A Fatal Medication Error — and…
One of the core ideas of the Toyota Production System is the recognition that people are indeed human and are therefore fallible (part of the “respect for humanity” tenet of TPS). No amount of “be careful” warnings will prevent all…
Study: Doctors Don’t Wash Hands Enough Over the weekend, in a trade publication, I read yet another survey about MD’s (especially surgeons) not washing their hands in between patients (under 60% of doctors). That’s not just a matter of being…
USATODAY.com – ‘Wrong site’ surgeries on the rise It’s supposed to be a standard practice, since 2004, for preventing “wrong site surgeries” — placing a big “X” on the surgical site, to prevent the surgical team from operating on the…
USATODAY.com – Your health You have to scroll down to see this on USA Today’s site, so here’s the whole article with my commentary. The idea of taking a water gun into your hospital room with you seems funny, if…
Washington Post (via MSNBC): Another example of the waste-filled health care system adopting TPS methods and approaches: “In adopting the Toyota mind-set, Kaplan said, the 350-bed hospital has saved $6 million in planned capital investment, freed 13,000 square feet of…
