BMJ  2007;334:169 (27 January), doi:10.1136/bmj.39101.389271.1F

Letters

Incident reporting

Seeing the picture through "lean thinking"

The first 150 words of the full text of this article appear below.

We have to take hospital safety out of the safety and quality ghetto and beyond strategies such as clinical audit and feedback that embed existing levels of error into baseline best practice outcomes.¹

For the past three years we have been experimenting with the application of "lean thinking" to care processes across our teaching general hospital.² Lean thinking is an approach to improving the sequential processes involved in production of manufactured goods and services of all kinds.

To the lean thinker, error in execution of a process is an absolute waste. No one benefits from it. Once it is acknowledged that errors resulting in an overt patient safety incident occur in one in five hospital admissions, further retrospective error analysis is of limited value. Simply adding another incident report to the existing pile will not change anything.³ Instead, we prospectively examine and redesign care processes of all kinds to make . . . [Full text of this article]

¹ Flinders Medical Centre, Bedford Park, SA 5042, Australia david.ben-tovim@fmc.sa.gov.au

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