Tag: Blame

Blame, Accountability, and Leadership in Lean

Blame is often mistaken for accountability—but in practice, it creates fear, silence, and surface-level compliance. These posts examine blame through a Lean and systems-thinking lens, showing how punishment-based responses undermine learning, psychological safety, and continuous improvement.

Across healthcare, manufacturing, aviation, and leadership culture, this archive focuses less on who to fault—and more on how leaders design systems that either encourage learning or drive mistakes underground.

Shigeo Shingo on Learning from Mistakes: Why “Foolproofing” Became Mistake-Proofing

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tl;dr: Shigeo Shingo and Norman Bodek understood that humans are fallible, and blaming people does not prevent defects. Mistake-proofing works when it respects people,...

Beyond Blame: How Punishing Healthcare Workers Fails to Prevent Medication Errors

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A nurse makes a medication error. A patient is harmed. The nurse already feels terrible -- they went into healthcare to help people, and...

When Life Tests You: My Attempt to Donate a Couch Was...

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tl;dr: In this post, Mark recounts his frustrating experience attempting to donate a couch, only to be stymied by bureaucratic obstacles. Using this personal...

Accountability in Leadership: A GM Flashback on Blame, Fear, and Culture

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TL;DR: A GM flashback shows how blame-based, command-and-control leadership destroys accountability instead of creating it. Real accountability starts at the top--when leaders model learning,...

Just-in-Time vs. Short-Term Thinking: What Really Caused Supply Chain Failures?

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True Just-in-Time (JIT) is about short, stable supply chains, production leveling, built-in quality, and long-term thinking--not zero inventory. What many companies practiced instead was...

Wrong-Side Surgery and the Pressure to Cover It Up: A Patient...

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TL;DR: Wrong-side surgery is a system failure, not just human error. Fear, silence, and lack of psychological safety allow mistakes to be hidden--making repeat...

Stop Blaming Workers: How Psychological Safety Prevents Harm and Improves Safety

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TL;DR:Blaming workers after mistakes makes organizations less safe. Psychological safety shifts the focus from "who failed" to "what in the system allowed this to...

How to Be Logical and Kind When a Mistake Is Made...

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In this post: How to respond logically instead of emotionally when a mistake is made Why kindness matters just as much as root cause analysis How to...

When Hospitals Punish Necessary Workarounds Instead of Fixing Broken Systems

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TL;DR: When staff invent workarounds to cope with shortages or failures, the real problem isn't their behavior--it's the system leaders allowed to fail. This blog...

Third Time’s the Charm for the Iced Tea — On Errors,...

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This past weekend, an old friend came down from Michigan to spend two days in the Dallas area. Amongst the activities and catching up, we...

The Academy Awards Add an Inspector, Practice “Andon Cord Pulls,” Avoid...

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Tomorrow, my post will be about headlines that scream about ratings for The Oscars being "down from last year" or "the lowest in X years." As I've blogged about before, I'm always skeptical of such simplistic comparisons that might mask the real underlying trend. But first, could the Academy avoid last year's embarrassing mixup?

Lessons from NUMMI’s 10th Anniversary Book: Respect, Teamwork, and Lean Leadership

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I did manage to buy a book that was published by NUMMI to celebrate their 10th anniversary. "10 Years of Quality & Teamwork" is the title. Here is the cover and I'll share a few things that caught my attention inside. It's interesting to think through this book in the context of : Tesla (the current owners of the building - see my past blog post) Healthcare organizations
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