Corpus Christi, Texas:
Hospital error blamed for more infant overdoses - Yahoo! News
Key points of the story are:
14 babies received heparin overdoses while in intensive care.
Two premature twins died, though it is unknown if this was the cause.
…pharmacy workers at Christus Spohn Hospital South made what the hospital called a "mixing error." The two [...]
More than a few organizations I know are starting to understand the importance of establishing a culture of problem solving. Hopefully they are shifting from a tools implementation model to one which emphasizes how people respond to the daily friction generators.
In an email on the topic to a friend today, I cited four things that [...]
In a short, but interesting, thread on
lean.org, Emma asks an interesting question: “Can an IT system support Lean?” She goes on to point out a general trend she has seen where the “kaizen guys” offer a lot of resistance to the introduction of sophisticated I.T. systems.
“Lean” stuff aside, I offer this recent post on [...]
This is a (belated) response to a post from Patsi Sells on The Whiteboard. She asked about safety and kaizen.
When first implementing some of the tools and mechanics of the TPS (especially in a manufacturing environment), many of the initial efforts seem to run afoul of the industrial safety professionals. My experience suggests a couple [...]
When real effort is spent getting to the cause of problems (vs. a reflex to find someone to blame), ambiguity often enters into the picture.
Problem solving is a process of asking questions and clarification.
Is a “defect-free” outcome of the process specified? Does the Team Member know what “success” is?
Is there a way for the Team [...]
Today I flew from my home in the Seattle area to New York’s La Guardia airport. This seems to nearly always be an adventure, but this one was unusual, so I wanted to comment on the customer’s perspective.
The flight routed through the airline’s major hub in Minneapolis (MSP) (so now you know which airline if [...]
If I were to look at the experience of the organization profiled in the last three posts “A Systematic Approach to Part Shortages” I believe their biggest breakthrough was cultural. By applying the “morning market” as a process of managing problems, they began a shift from a reactive organization to a problem solving culture.
I can [...]
The third element of this organization’s successful drive to eliminate part shortages was a systematic approach to problem solving. They made it a process, managed just like any other process, rather than something people did when they had time. Even though this is “Part 3″ of this series, in reality they put this into [...]
For kanban to work well, there has to be a solid foundation under it. That foundation is production leveling or heijunka.
Before I get to far into this, though, I would like to point something out: At the mention of leveling, people who are only just learning about kanban will point out all of the good [...]
One of the displays in the Toyota Museum in Nagoya was an exhibition on “Universal Design.” This exhibition runs through December 2.
Rather than trying to interpret and articulate the concepts, I just want to list some of the key words. I think they stand for themselves, and provide a good baseline for evaluating the design [...]