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.
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 suing the maker of the drug, Baxter, claiming the company is negligent for not designing…
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…
Our Unsanitary Hospitals – WSJ.com That’s “Clean”, not a typo of “Lean.” Good column in the WSJ today by Betsy McCaughey, head of the Committee to Reduce Infection Deaths organization (link). She asks why restaurants and meat packing plants get…
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 me tell the story. I’ve been battling what’s either severe allergies or a mild cold for…
I saw this ad (click on the photo for a larger, readable view) in the Wall Street Journal Monday. It’s an ad run by a patient advocacy organization called “RID” (Reduce Infection Deaths). The headline is “15 Steps You Can…
Patient Safety Blog – Telling Our Stories Here is an unfortunate story about a surgeon operating on the wrong side of an 86 year-old man, who died sooner after. There’s no clear cause-and-effect between that error and death: The surgeon…
The Informed Patient – WSJ.com Here’s an article ($$) about hospitals working to prevent bedsores or “pressure ulcers” as they are called. I didn’t get around to blogging about this more fully, but it was in the news recently that…
APM Marketplace (Business/Economy radio) As you’ve read here, I’m trying to help get the word out that we should be not just focusing on access to care, but also focusing on quality of care — preventable medical mistakes. I think…
The Informed Patient – WSJ.com This article from the WSJ talks about a trend where patients (or, more often, family members of patients) who were injured or killed by medical mistakes are dedicating their lives to improving patient safety for…
Study: Hospital Goals Sometimes Compromise Safety With Lean, we have realized that improving quality does not run counter to decreasing costs. They go together. Using Lean methods, improving flow, error proofing and reducing defects, leads to decreased costs in any…
globeandmail.com: Private sector health care: Think quality, regulation I don’t think healthcare and quality is a “Private vs. Public” debate. As we’ll inevitably have debate during the 2008 U.S. Presidential election, I think it’s important to keep quality in mind…
Ledger-Enquirer | 03/27/2007 | Campaign’s goal is to reduce infections To those who might have thought I overstated the situation with hand washing in hospitals, here’s another article about maintaining proper hygiene among hospital staff and caregivers. One particular risk…
