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January 2015
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Perspectives on Safety
Lean and Patient Safety
In Conversation With… Mark Graban, MS, MBA
Mr. Graban is an internationally recognized expert in Lean Healthcare. We spoke with him about applying Lean in hospitals to improve safety and decrease waste.
(.MP3 | 11.4 MB)
Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care
by Paul E. Plsek, MS
This book excerpt describes how integrating innovation and Lean concepts at Virginia Mason enhances clinical performance and the patient experience.
Cases & Commentaries
A woman who had an uncomplicated pregnancy and normal labor with no apparent signs of distress delivered a cyanotic, flaccid infant requiring extensive resuscitation. Although fetal heart rate tracings had shown signs of moderate-to-severe fetal distress for 90 minutes prior to delivery, clinicians did not notice the abnormalities on the remote centralized monitor, which displayed 16 windows, each for a different patient.
Commentary by Mark W. Scerbo, PhD, and Alfred Z. Abuhamad, MD
CME/CEU credit available for this case

Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia.
Commentary by Krishna Moorthy, MD, MS

While undergoing an elective coronary artery bypass graft (CABG) and ablation, an elderly man had a pulmonary artery catheter (PAC) placed to monitor his hemodynamic status. During the operation, the team was informed that another patient needed an emergency CABG. In the rush to attend to the second patient, the PAC in the first was left inflated for a prolonged period, which could have led to a catastrophic complication.
Commentary by John H. Eichhorn, MD
Photograph of doctor using a computer
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