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.

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.

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.

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.

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.

Recorded live at Meow Wolf in Santa Fe, this episode features a wide-ranging conversation between Todd and Andy Baker about learning, safety culture, and leadership influence. They dig into HOP and related safety approaches, debate top-down versus middle-out change, discuss the importance of language and unlearning, and explore how to turn belief into practical skill and behavior. The episode offers real-world insights on piloting change, engaging leaders and middle managers, and learning from others who have adapted these ideas in novel ways.

Tiny Todd Conklin joins the No Way Out podcast to explore Human and Organizational Performance (HOP), high-reliability organizing, and how safety emerges from complex systems rather than individual mistakes. They critique traditional investigations, surveys, and risk matrices, and discuss practical ideas for building capacity, worker agency, psychological safety, and resilient operations.

This episode examines the growing problem of children accidentally left in hot cars, explains why memory failures can happen to anyone, and argues that punishment is not the solution. It summarizes practical approaches—accepting the risk, assuming "when, not if," using technology and visual reminders, and responding with understanding rather than judgment—to create system-level changes that improve recoverability and prevent future tragedies.

Todd talks with Lauren Mooney about her book High Reliability in Action and how to translate HRO concepts into practical behaviors. They cover the rise of HRO, the 'Speaking In' approach, nine guiding questions, and the animal avatars that represent attitudes like humility, courage, and curiosity. The episode emphasizes leadership’s role, DIY team practices for recognizing risk, responding early, and adapting effectively across industries—from frontline staff to executives.

This episode of the Pre-Accident Investigation Podcast features patient safety leader Lisa Zegan, host of Tales from the Sharp End, in a candid conversation with Todd about the 2017 Vanderbilt medication error and what it reveals about healthcare systems. They explore why criminalizing mistakes harms learning, how design and billing pressures shape medication cabinets and workflows, the limits of “zero harm,” and the case for recoverability/rescuability, cross-industry learning, and leadership-driven transparency across hospitals.