On Super Bowl Sunday in February, an 18-month-old boy was pulled from his family’s pool in Gilbert, Arizona, and rushed to Mercy Gilbert Medical Center. He was pronounced dead at 6:20 p.m. At 11:52 p.m., staff from the medical examiner’s…
Someone in a meeting sees a problem coming. Maybe it’s a risk in the plan, an assumption that doesn’t hold up, or a direction that doesn’t feel right. They don’t say anything. The meeting moves on, and the moment passes.…
In July 2013, on a test drive in the United States, Martin Winterkorn, the CEO of Volkswagen, noticed a paint imperfection on a Beetle. The paint was slightly thicker than the company standard. Less than a millimeter too thick, according…
Thanks, as always, to Ryan McCormack for this. He always shares so much good reading, listening, and viewing here! Subscribe to get these directly from Ryan via email. News, articles, books, podcasts, and videos about how to make the workplace…
I’m traveling internationally for ten days and I turned on one of the British news channels. There’s a major story about NHS England. First, the awful reality that a nurse would willfully kill babies in the NICU. Then, the second…
Hospitals have Quiet Rooms now. There’s soft lighting. There’s a chair. There’s a noise machine, which is a machine that makes calming noises. There’s sometimes a succulent in a small white pot. The succulent is doing fine, which makes sense,…
Twice in the past two weeks, I have talked with people who want to write a book about Lean. Both were early in the process and trying to figure out what they were signing up for. I’ve had a lot…
My wife and I watched Freefall: A Reckoning for Boeing last night. It’s Rory Kennedy’s follow-up to “Downfall,” and it’s built around former Boeing employees, including quality managers and inspectors, describing what they saw on the floor and what happened…
GE was in bad enough shape in 2018 that investor Nelson Peltz says he was sure the company would end up in Chapter 11. Inside GE, meanwhile, business reviews were full of good news. Both things were true at the…
On Thursday, I wrote about the death of Donald Gough at the University Hospital of Wales in Cardiff. He received insulin during liver surgery even though he was not diabetic and had no clinical reason to be given it. That…
Somebody on the r/nursing subreddit asked what the worst medication error was that people had seen or heard about. Almost six hundred replies came in. I’ve read the whole thing, and there are a few ideas I want to come…
When I was a young engineer at GM’s Livonia Engine Plant in the mid-1990s, I wrote down some of the things production workers said to me. One of them stuck, a worker in a machining department: “I want to stop…
