Tag: Mistake-Proofing

Fire Fighting vs. Root Cause Problem Solving

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Below is some of the text from edition #3 of the newsletter from my upcoming book Lean Hospitals: Improving Quality, Patient Safety, and Employee...

Martin Hinckley on Mistake Proofing (Poka-Yoke) [Podcast]

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This is LeanBlog Podcast episode #42 with Dr.C. Martin Hinckley, of the firm Assured Quality. He is the author of the book Make No...

Error Proofing Vs. “Be Careful” – Which is More Effective?

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Why do you need a "be careful" warning message when you've already error proofed something? For liability's sake? I am going to be flying back...

Dennis Quaid on 60 Minutes

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Dennis Quaid Recounts Twins' Drug Ordeal, Actor Tells 60 Minutes' Steve Kroft Medical Errors Kill Thousands - CBS News Did you see the actor Dennis...

Another Pathology Mishap

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L.I. Hospital Scrutinized After Deaths of Patients - New York Times It wasn't the same laboratory this time, but it's more than likely a similar...

An Example of Vehicle Error Proofing

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Urban Legends Reference Pages: Cruise Control on Wet Roads HazardThis is sort of an old urban legend that has been making the rounds again,...

Quaid Case Update: Whose Responsibility is Standardized Work?

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If you're a regular reader, you might recall the Cedar-Sinai medical error that harmed Dennis Quad's twins (and others). Quaid and his wife are now...

Follow Ups to BIDMC

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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...

My At-Home Medical Mistake: Taking the Wrong Version of Day /...

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I'm a bit mad at myself for inflicting some preventable human error on myself last night. It's OK, I didn't harm myself, but let...

Adverse Drug Events and Harm in Hospitals – Follow Up on...

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Here are some follow-up articles, quotes, and data following up on the news from the other day that Dennis Quaid's twins were impacted by...

Updated: How Often Must the Same Mistake Be Repeated?

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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...

"Heightened Vigilance" is Not Enough

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The Sun Chronicle Online - OpinionA medical error was in the news this week, a teacher was mistakenly given an insulin shot instead of...
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