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.
Thanks as always to Ryan McCormack for this… Healthcare – Creating Value for Patients Virginia Mason’s 20 year pursuit of measurably better value for patients is paying off during pandemic-related travel restrictions through their innovative mix of telehealth and in-person care.…
Thanks as always to Ryan McCormack for this… Healthcare – Creating Value for Patients Health Care Workers Protect Us. It’s Time To Protect Them. Great article in HBR by Ken Segel and John Toussaint. Volume-based incentives drive behaviours — often…
Back in May, I shared the first episode of a podcast that I’m producing for the firm Value Capture… it’s called “Habitual Excellence.” I won’t do a blog post here for each new episode, but I did want to share…
Thanks as always to Ryan McCormack for this… Healthcare – Creating Value for Patients Electronic Health Records and Computerized Physician Order Entry were going to reduce errors and save lives by providing better clinical decision support and alerts for potential…
Today, I went for a brisk 50-minute walk on a sunny morning and my companion was the voice of the late Paul O’Neill as I listened to the audio from a video I’m sharing here. I listened to it and…
I had a phone conversation yesterday with an emergency medicine physician after her shift at an unnamed hospital in an undisclosed state. She had a number of frustrations to share and she doesn’t really have an outlet (and doesn’t want…
I’ve been thinking a lot about hospitals and how they’re preparing for the expected tsunami of Covid-19 patients who will need ICU beds and ventilators (when it’s expected that there won’t be enough of either). There have also been recent…
Returning for Episode #360 of the podcast is Leah Binder, the president and CEO of Leapfrog Group. We last talked four years ago in Episode #240 about the patient safety crisis and efforts to improve. Today, we’ll talk about hospitals’…
Here is a story that was sent to me by a blog reader, who needs to remain anonymous. I know the blog reader fairly well and believe what’s written here to be true. The blog reader is a career-long Lean…
TL;DR: In healthcare huddles, how leaders ask about patient safety can either invite honest discussion or make speaking up feel risky. Open-ended, system-focused questions–combined with consistent follow-through–are essential for building psychological safety and preventing harm. I think that working to…
TL;DR: Two Japanese hospitals improved patient safety by combining Toyota-style problem-solving with psychological safety. By making it safe for staff to report problems and near misses, leaders uncovered more issues, learned faster, and reduced harm–turning safety into part of daily…
tl;dr: When doctors and nurses are afraid to speak up about safety risks, problems stay hidden and patients are harmed. Real cases from the UK show how fear, retaliation, and leadership behavior undermine patient safety, while true improvement requires psychological…
