Amy Edmondson
speaker
344 appearances
1 recordings
1 series
first heard Aug 2026
last heard 3 Aug
Amy Edmondson’s voice in public audio — every appearance, attributed to the second.
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recordings per month · last 12 monthsRecordings per month over the last 12 months — 1 in all, peaking in Aug 2026 with 1.
Appearances
And then finally the medication label was printed badly by IT and a little difficult to read, so that contributed to them not able to determine the concentration of the drug exactly right.
And so all of those holes in the Swiss cheese lined up and let this overdose go through.
Fortunately, it was noticed very quickly and they called the physician and instantly delivered a drug to help correct the error.
But it's the kind of story that is unfortunately common in healthcare, but especially in any complex system.
That's absolutely right.
And our tendency is to look for that smoking gun.
Our brains are used to looking for the single cause, the small part that broke, rather than to back up and see how the parts are relating to each other and coming together in a way that created the failure or created the flaw.
And it's a discipline to sort of realize that there's multiple factors.
And in order to
To prevent complex failures, speaking up is essential.
People need to know that their voices are welcome because all you have to do is catch and correct one of the many factors and you've prevented the failure.
Toyota is one of the best examples of doing this well.
And probably the best practice that is maybe even the most famous of the Toyota production system is something called the Andon cord.
And that is a literal cord that
that any team member is encouraged to pull whenever they see something wrong, or even more importantly, whenever they see something that might be wrong.
Now, many people think once you pull the cord, the line instantly stops.
It doesn't.
When you pull the cord, what happens is that a team leader comes quickly over and says, what do you see?
And you explain and
And the two of you together diagnose what's happening.
Showing 161–180 of 344 · page 9 of 18
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