Intended for healthcare professionals

Letters Incident reporting

Seeing the picture through “lean thinking”

BMJ 2007; 334 doi: (Published 25 January 2007) Cite this as: BMJ 2007;334:169
  1. David I Ben-Tovim, director, Redesigning Care and Clinical Epidemiology Units
  1. 1Flinders Medical Centre, Bedford Park, SA 5042, Australia

    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 doing the right thing easier than making errors. A prospective examination of existing processes, to identify potential weaknesses and opportunities to improve, encourages the improvement team to work at the system level rather than the level of individual blame.4 It also avoids sterile debate about relative risk.

    Over three years, we have halved the number of serious safety events that have had to be reported to our insurers, despite a substantial increase in the numbers of patients seeking care in our hospital. At the beginning of our lean thinking journey, our hospital was struggling to contain a deficit. In the last financial year, we were several millions dollars in the black accomplished without extreme measures such as shedding staff.


    • Competing interests: None declared.