tl;dr: Many people misuse the 5 Whys by asking five loosely related questions rather than a sequential chain of cause and effect. Real root cause analysis requires disciplined logic–each “why?” should build directly on the last. This post explains how…
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…
So I’m finally watching the DVR-ed episode from March 10, 2009, that gave widespread exposure to the issue of medical mistakes. Oprah began the show by citing the statistic that errors cause more deaths than “breast cancer, AIDS, and car…
Curious at Amazon, but Not Idle – Bits Blog – NYTimes.com This piece about Amazon’s CEO Jeff Bezos made me think about visiting the “Gemba” (the Japanese term that means “the actual place” — the place where work is done).…
Kevin Meyer, over at Evolving Excellence, recently wrote a good piece on “endorsing” a U.S. presidential candidate. Today, I’m technically Constitution-eligible to be President of the United States, as I’m now 35 years young. However, I’m not nominating myself to…
Pharmacy transformed at Women and Children’s Hospital Here is a story about a Buffalo hospital that designed a new pharmacy space. The article doesn’t mention Lean… although I know of many hospitals that have used Lean methods in a pharmacy…
Star-Telegram.com: | 05/06/2008 | LETTERS OK, so we’re piling on JPS Hospital at this point.. but this letter to the editor caught my eye today: One glaring omission in your series was failure to critique the pharmacy. It’s one of…
If you’ve been following any of the posts about healthcare, here are a few interesting follow ups. Following up on this post about Boston’s Beth Israel Deaconess Medical Center, CEO Paul Levy posted many interesting employee responses to his email…
Dennis Quaid’s newborns reportedly harmed by medical mix-up – Los Angeles Times (Updated 4:57 PM, again at 9:51 PM, see bottom of post) If this story sounds familiar, it’s because it is the exact same error as one that killed…
Phila. health agency in disarray | Philadelphia Inquirer | 09/26/2007 I saw this in the news as I was leaving Philly earlier this week. Would you run your manufacturing warehouse like this? Dell keeps better track of computer parts than…
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…
Fatal Dose: Ohio Girl is Killed By Medical Mistake Here is a sad story of a girl’s death due to a hospital pharmacy mistake. Pharmacies oftentimes just repackage and dispense “off the shelf” drugs (such as pills), but they often…
