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 583 - When Normal Variability Breaks: The ReDonda Story
This episode previews a small workshop in Santa Fe where Todd Conklin, Ann Lyren
PAPod 582 - Accountability vs. Blame: Who Really Owns Safety?
Todd Conklin breaks down why accountability is an act of clarity, not blame or d
PAPod 581- Measuring the Invisible: When 'Nothing Happened' Breaks Safety Metrics
Todd Conklin explores why its so difficult to measure events that never happen a
PAPod 580 - Start Right, End Safe: Building Better Encounters in 2026
Todd Conklin opens 2026 reflecting on why how we begin interactions and jobs mat
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