Healthcare Archives - The Mistakes That Make Us

November 26, 2023

Preventing Mistakes in Healthcare – An Excerpt from ‘Lean Hospitals’

The following is an edited and annotated excerpt from my Shingo Award-winning book Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. To me, “mistakes” and “errors” are synonyms, so a discussion of “mistake-proofing” is the same as “error-proofing.” A Serious Problem With Large, Unknowable Numbers It is hard to… Read More "Preventing Mistakes in Healthcare – An Excerpt from ‘Lean Hospitals’"

by Mark Graban 542 Views Leave a comment

October 9, 2023

A Tragic Oversight: How Misunderstandings and Staffing Shortages Led to a Patient’s Death in the ICU

In an unsettling tale from within our hospitals, a friend recently relayed an alarming incident. It’s a story that unveils the complex challenges our healthcare professionals grapple with and the silent crises that occasionally go unnoticed. A diligent nurse, fresh out of school with just a year’s experience under her… Read More "A Tragic Oversight: How Misunderstandings and Staffing Shortages Led to a Patient’s Death in the ICU"

by Mark Graban 364 Views 1 Comment

September 12, 2023

Comparing Pharmacy Mistake-Proofing Methods: Which Is More Effective in This Case?

In the book, Chapter 4 focuses on preventing mistakes, including methods like checklists and mistake-proofing. We should really try to avoid and prevent medication mistakes, considering the harm that can result (up to and including death). We can try to prevent mistakes while also emphasizing the need to learn from… Read More "Comparing Pharmacy Mistake-Proofing Methods: Which Is More Effective in This Case?"

by Mark Graban 307 Views Leave a comment

September 8, 2023

How an Operating Room Error Nearly Cost Arnold Schwarzenegger His Life

In the news: Arnold Schwarzenegger Had Botched Heart Surgery Three Months Before ‘Terminator 6’ Filming, Doctor Poked Through Heart Wall: ‘I Was in the Middle of a Disaster’ What happened has been described as a “mistake.” “Schwarzenegger remembered the doctor telling him when he woke up, “We made a mistake… Read More "How an Operating Room Error Nearly Cost Arnold Schwarzenegger His Life"

by Mark Graban 359 Views Leave a comment

September 8, 2023

Learning from the Grave Mistake of Losing a Patient’s Removed Tumor

Being oriented around learning from mistakes doesn’t mean we are flippant about mistakes and human error. There are some mistakes that we should work really hard to prevent through checklists, mistake-proofing methods, and good systems. Telling people to “be more careful” isn’t really effective. I saw this in the news… Read More "Learning from the Grave Mistake of Losing a Patient’s Removed Tumor"

by Mark Graban 363 Views 1 Comment

September 5, 2023

NHS Apology Over Care Mistakes Includes Wishing Deceased Patient ‘Future Wellbeing’: A Deep Dive

In the news: ‘Catalogue of errors’ in treatment of terminal man Leslie Boatfield died of bowel cancer. His surviving daughter complained about a series of errors. “It was a catalogue of errors and people not doing things,” Ms Price said. It doesn’t make everything OK, but “the University Hospitals Sussex… Read More "NHS Apology Over Care Mistakes Includes Wishing Deceased Patient ‘Future Wellbeing’: A Deep Dive"

by Mark Graban 332 Views Leave a comment

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