PAPod 569 - PART TWO: 11 Seconds: How a System, Not a Nurse, Failed
Part two of the RaDonda Vaught story examines what emerged after the event: investigation details, system design flaws, communication breakdowns, and the tiny timing error that mattered. RaDonda Vaught recounts how normalized overrides, software defaults, and organizational assumptions created conditions for failure.
The episode explores the chilling effects of criminalizing mistakes, the human cost across patients and providers, and the case for shifting from blame to system-focused learning and improvement.
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30:31
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30:31
PAPod 568 - PART ONE: Charged for a Mistake: The Nurse, the Error, and a System That Failed
In this episode, nurse RaDonda Vaught tells the detailed, context-rich story of a medication error at Vanderbilt that led to criminal charges. She walks through the events, system issues (including a recent EHR rollout and medication-dispensing delays), distractions, and decision points that contributed to the mistake.
RaDonda describes how workarounds, unclear documentation in radiology, drug supply changes, and interruptions combined to produce a tragic outcome, and she explains the immediate clinical response. The episode sets up a follow-up discussion about what was learned and how systems can be improved.
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44:31
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44:31
PAPod 567 - Open Questions 2025: From Metrics to Monitors — Rethinking Safety
Episode: an extended open Q&A from the Pre-Accident Investigation Conference in Santa Fe covering big-picture safety topics.
Speakers discuss the limits of traditional metrics, the power of real-time monitoring, shifting focus from managing risk to maintaining control, validating controls in the field, learning teams, contractor relationships, and prioritizing high-information events. Anecdotes and practical guidance illustrate how organizations can learn without blame.
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51:18
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51:18
PAPod 566 - Blame Stops Improvement: How Blame Silences Learning
Todd Conklin explores how blame shuts down learning and prevents organizational improvement, arguing that blaming individuals creates a chilling effect that blocks thousands of future learning opportunities.
He connects blame to misunderstandings about human error, emphasizes psychological safety, and urges leaders to ask "what failed" before asking "who failed," while sharing personal anecdotes and reflections.
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22:46
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22:46
PAPod 565 - Fear, FOMO & Fixing Safety: A Conversation with Brent Sutton
Todd Conklin and Brent Sutton discuss the short-term future of safety thinking—covering the rise and fall of lean/TQM, how commodification can slow innovation, and why fear, FOMO and complacency shape which ideas stick. They explore leaders' responsibility, weak signals, and the need for small 'safe-to-fail' experiments to keep systems resilient.
Set in Santa Fe with lighthearted moments (including breakfast burritos and a cheese debate), the episode blends history, practical insight and a call to stay curious about evolving workplace complexity.
Ireland