Case Studies
Infants receive wrong mothers milk in intensive care - how a resilimap learning team resolved the problem
A pediatric intensive care facility was experiencing events of delivering expressed milk to the wrong infant. An expert lean thinking team was assigned the task to solve the problem and were unsuccessful. A resilimap learning team (RLT) was established to harness the insights of the frontline workers. The RLT identified the source of the error in the two-factor identification method relating to human factors. They designed a new identification method to match the infants with their mothers expressed milk. The new method resolved the problem. Watch the video to see this innovative human factors solution.