PAPod 568 - PART ONE: Charged for a Mistake: The Nurse, the Error, and a System That Failed

This episode explores human performance and aviation safety, contrasting airline procedures with general aviation risks. Guests discuss building safety margins, the importance of planning vs. acting, and how economic pressures can erode resilience. Highlights include treating near-misses as learning opportunities, practical tips for pilots to increase recoverability, and real-world examples from naval operations and long-term flying experience.

Jay Allen interviews Todd Conklin about his new book, The Stability Trap, exploring why even safe, stable organizations can fail. They discuss the "drive to zero," complacency, pressures on middle management, wearables and data, and lessons from aviation and the pandemic. The episode also covers how AI was used to reorganize the book’s ideas and help craft its ending, and offers practical reframes: treat safety as a capacity, see workers as system monitors, and retool systems to match capacity with risk. The book is available now.

Host Todd introduces his new book, The Stability Trap, and shares a sneak peek episode created with an AI-generated interview. The episode explores why organizations that appear safe can still experience accidents and how success itself can erode safety capacity. The discussion outlines the core ideas: safety as the presence of capacity, the three R's (redefine safety, reframe the worker, relearn investigation), and a five-stage practical blueprint for leaders, safety professionals, frontline workers, supervisors, and system integration. Short and practical, the episode is a teaser for the book and invites listeners to reflect on whether their organizations maintain the resilience, confidence, and systems needed to recover when things go wrong.

In this episode Todd Conklin joins Jowanza Joseph to explore modern safety thinking: why human error is normal, how context shapes behavior, and why leadership response and system recoverability matter more than blame. They draw on examples from Los Alamos, AWS outages, SpaceX and everyday technology to show how organizations can design systems that tolerate failure and learn from it. Listeners will get practical insights into the five principles of human performance and how to build resilient systems that fail safely and recover quickly.

Todd Conklin joins the Brisbane Safety Differently Book Lab in Auckland for a lively discussion about leadership, accountability, and learning from everyday work. The group explores why safety is the presence of control, how leaders should respond after incidents, and why learning is the new currency of safety. Todd shares stories about writing his books, engaging with workers, and practical steps leaders can take to build confidence and capacity while fostering a learning culture.

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.