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.
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…
Actually being a patient in the emergency department is a learning experience, to say the least. I've done that twice in the past twelve months (two cases of really bad stomach flu with high fever). I don't recommend this if you can avoid it.
What I do recommend is an interactive learning experience called "Friday Night at the ER."
More about that in today's post...
My guest for Episode #317 of the podcast is Patricia Morrill, a speaker, trainer, consultant, researcher, and author of the book The Perils of Un-Coordinated Healthcare: A Strategic Approach toward Eliminating Preventable Harm.
With 30 years of experience in the healthcare industry, she has focused on blending operational efficiencies with healing environments. Patricia has successfully integrated Lean and Project Management methodologies with organizational strategic goals to build roadmaps for execution. Check out her website and her blog.
In today's episode, we discuss her personal story about her mother's death that came as the result of a preventable medical error. What can be done to prevent medical errors, harm, and death?
Mark's Note: I asked my firiend Sam Selay to write a blog post on this topic after some private discussions that we had. He agreed and shared this post. I've talked to many others who have run into similar roadblocks and frustrations when trying, with the best of intentions, to bring their Lean skills and experience into healthcare.
Sam was one of the contributing authors to the anthology "Practicing Lean," which is now available through Apple iBooks, in addition to Amazon (Kindle and paperback), and Leanpub (eBook and audiobook). Here is his post:
In June, I was informed by my employer that the company had decided to go in a new direction. They said they would now build lean into their processes and enable process owners to be responsible for all continuous improvement functions. To date, I don’t know many organizations that have been able to successfully embed lean into everyone’s work and sustain it.
Joining me again for Episode 310 is Stephen M. Shortell Ph.D., MPH, MBA. He is Blue Cross of California Distinguished Professorship, HPM and is a Professor of Organizational Behavior at the University of California, Berkeley School of Public Health.
He was previously a guest on Episode 267 talking about the establishment of the Center for Lean Engagement and Research (CLEAR) at the University of California, Berkeley, where he is the director.
In this episode, we talk about some initial research that they released in a paper that was published in The Joint Commision Journal on Quality and Patient Safety:
"Use of Lean and Related Transformational Performance Improvement Systems in Hospitals in the United States: Results From a National Survey"
It's great to see Lean healthcare featured in one of the world's leading news and business publications. The Economist recently published this article:
"Hospitals are learning from industry how to cut medical errors"
I'll be teaching my "Better Metrics" workshop (aka "Measures of Success," ala my book) twice in June:
Cambridge Investments - Open for Public Registration (Fairfield, Iowa) -- June 5
Lean Healthcare Transformation Summit (Chicago) -- June 13
After facilitating the Red Bead Experiment in the workshop, one other way I've found to simulate variation is an online simulation that's available, of all places, on the BBC website:
"Can chance make you a killer?"
Healthcare is full of terms that obfuscate things. Ironically, use of the word "obfuscate" can be an example of obfuscation.
Instead of saying, "Healthcare leaders often obfuscate a situation," we can say, "The language used in healthcare often makes things sound better or more complicated than they really are."
TL;DR: Captain “Sully” Sullenberger’s leadership lessons from Flight 1549 highlight that safety depends on humility, trust, teamwork, and learning from mistakes–not heroics or checklists alone. High-risk industries like aviation improve safety by focusing on systems, psychological safety, and fact-based decisions.…
Today's post is my eighth cartoon collaboration with a skilled artist and medical assistant, Carrie Schurman (see past cartoons). You can find her on Twitter as @carrieschurman.
