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.
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: inve
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
PAPod 567 - Open Questions 2025: From Metrics to Monitors — Rethinking Safety
Episode: an extended open Q&A from the Pre-Accident Investigation Conference in
PAPod 566 - Blame Stops Improvement: How Blame Silences Learning
Todd Conklin explores how blame shuts down learning and prevents organizational
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