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.
It’s the annual National Patient Safety Awareness Week, just ending now. Here are my thoughts from last year, including my stance that EVERY week needs to be patient safety week. The problem is big enough that we need awareness increasing…
It’s time again for a regular feature I call “Stuff I’m Reading.” I have too many browser tabs open and my Mac is bogging down (root cause of this?), so it’s time to share some links that I may or…
I recently saw this headline in the London Evening Standard: “Nurses struggle to ‘get the job done’ due to staff shortages and lack of time on 12 hour shifts.” The article starts with jumping to solutions (needing/wanting more staff), but…
Many of you who took my reader survey (still open and feedback welcome, prizes gone) mentioned that you liked this style of post with links to stuff I’ve been reading. I am to please… Some links to web articles I…
Last year, the Institute of Medicine released its latest report titled, “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” The report endorsed Lean as one strategy for improving the problems in our health care…
While working in different environments and different industries, I’ve seen many work requirements that were deemed “non-negotiable” by management – and rightly so. For example, wearing safety glasses in a factory or wearing gloves when handling specimens in a hospital…
Last week, my wife was watching ABC’s show “Grey’s Anatomy,” as she always does. Again, as she often does, she’ll pause it for me when there’s a scene related to patient safety, so I can watch. In this scene, below,…
Karen Wolk Feinstein, president and CEO of the Pittsburgh Regional Health Initiative, channeled the Saturday Night Live Weekend Update segment “Really!?!” in this recent op-ed titled: “Don’t put this on patients: Sick people are supposed to monitor medical errors? Really??“…
The list of stuff I’ve read and wanted to blog about has grown… that inventory becomes a post like this. Here are links to some varied articles I’ve read recently that might be of interest on a number of Lean…
Mark’s Note: Today’s guest post is, again, from a great friend of mine and this blog, Dean Bliss, of the Iowa Healthcare Collaborative. Check out my podcast with him. By Dean Bliss In my role as a Lean healthcare worker,…
The list of stuff I’ve read and wanted to blog about has grown… that inventory becomes this post. Here are links to some varied articles I’ve read recently that might be of interest on a number of Lean related topics,…
Many of you have emailed me about this horribly sad story: “Toledo hospital nurse accidentally throws away healthy donor kidney during transplant surgery.” As a blogger, I wish I could go to the “gemba” to really help investigate and find…