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.
Healthcare – Creating Value for Patients The last place I want to receive care is the hospital. There are innumerable advantages to being treated in home for the patient, family, and healthcare system. Treating acute care patients in the home…
tl;dr: High-profile “never events” aren’t caused by careless clinicians–and they aren’t prevented by warning signs. Signs that tell people to “be careful” substitute reminders for real system design, error-proofing, and a culture that makes it easy to do the right…
Healthcare – Creating Value for Patients An experienced doctor in Toronto caused harm, operated without consent, and intimidated staff for years. A disturbing but unsurprising tale of greed, betrayal, and medical misconduct at North York General Hospital. One way to better…
TL;DR: Lean improvement depends on asking both “why?” and “why not?” Leaders who challenge assumptions and refuse to accept “we’ve always done it this way” unlock innovation in patient safety, flow, and quality. Asking “why not?” turns barriers into design…
My guest for Episode #341 of the podcast is Dr. Rob Hackett, an anaesthesiologist in Sydney, Australia. Rob has become known around the world for his role in what’s now called the “Theatre Cap Challenge” — a method for improving…
TL;DR: Dr. Gary Kaplan describes Virginia Mason’s adoption of Lean as a “war on waste,” but the real impact goes beyond waste reduction. By applying the Toyota Production System as a management system–not just a set of tools–Virginia Mason improved…
Mark’s note: This post is reprinted from an email from Laura Batz Townsend, the CEO of the Louise H. Batz Patient Safety Foundation. I asked to share it here, on the tenth anniversary of Louise Batz’s tragic death that was…
My typing is a bit hampered after my finger surgery still. At least my surgery was safe and my outcomes seem to be good. Not everybody is so lucky. This week is the annual Patient Safety Awareness Week. In this…
TL;DR: Pursuing zero harm isn’t about unrealistic goals or punishing people for failure. It’s a leadership choice that creates psychological safety, accelerates learning, and strengthens Lean systems. When organizations treat safety–physical, emotional, and professional–as a non-negotiable value, improvement capability follows…
tl;dr: Human error is inevitable–even for experienced professionals. Forgetting socks on a work trip is harmless, but similar mistakes in healthcare or organizations can cause real harm. The lesson isn’t to “be more careful,” but to design better systems that…
Mark’s note: Mike Sporer has commented a few times on blog posts and I invited him to write this guest post after we exchanged some emails about his recent experience as a hospital patient. I recently had a surgical procedure…
Joining me today for Episode #329 of the podcast is Mike Eisenberg, the director, editor, and producer of the film “To Err is Human,” a documentary about the incredibly important issue of patient safety. The film shares a title with the…
