In the ICU, ER, and surgical suite, the requirement to flawlessly perform on demand while under pressure is every bit as high as it is in...

Whether it's in the cockpit of a modern commercial airliner or a Navy fighter jet, great decision-making can mean the difference between...

Let's see how a well-known surgeon answers that question. This Boston surgeon performed the wrong procedure on the hand of an elderly...

In military and commercial aviation and elite firearms training, stress inoculation is a fundamental component used to prepare...

A study of the effectiveness of debriefing revealed that in 44 months of use, the debriefing process identified 6202 defects in processes...

Eliminate distractions We used to hear the flight attendant command passengers to turn off their cell phones once the cabin door was...

Years ago, when the commercial airline industry was first beginning to implement Crew Resource Management (CRM or “TeamSTEPPS” as it is...

Last week in my blog about quality improvement entitled, “Make Sounds Come Out of Their Mouths” I made what I thought was a very simple...

Recent research has revealed a simple, but totally effective tool for getting your staff to speak up every single time they perceive a...

...If not, the Time Out won't eradicate harm According to a report in the Archives of Surgery, patients undergoing surgery still risk...

Skip these important leadership steps and your new improvement project becomes a three-legged race you can’t win. (Read to the end for...

In this pandemic crisis leaders are not only at war with the COVID-19 virus, they are also at war with the debilitating effects of...

Use this checklist to beat the 70% failure rate of change initiatives. Without a tool like this, your odds of success are slim.

Scorecards drive better performance. The evidence is clear that solid feedback in the form of a measurement scorecard enhances...

47 percent of patients lost a diagnosis when transferring between hospitals, according to a recent study. Data from more than 180,000...

Frequency of never events Although most never events are rare, these safety incidents can have significant effects on patients and...

A new study reveals that team training in healthcare can reduce medical errors by 19 percent. Team training can also reduce patient...

Today begins Patient Safety Awareness Week. Many healthcare leaders will acknowledge it, but are actually hiding from it. They do this in...

By now almost everyone involved in health care quality improvement has heard of the checklist used to insert central lines that was...

A Boston surgeon who performed the wrong procedure on the hand of an elderly woman has disclosed the excruciating details of his error in...