PAPod 568 - PART ONE: Charged for a Mistake: The Nurse, the Error, and a System That Failed
Episode 931
PreAccident Investigation Podcast
The Pre Accident Podcast is an ongoing discussion of Human Performance, Systems Safety, & Safety Culture.
Show Notes
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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