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.
PAPod 576 - From Continuous Improvement to Continuous Capacity: 10 Operational Indicators You Need
This episode shifts the safety conversation from continuous improvement to conti
PAPod 575 - Vancouver Workshop: A Case Study in Failure, Justice, and Resilience
Todd Conklin talks with Brent Sutton and Jeff Lyth about the upcoming HOP Worksh
PAPod 574 - Margin for Safety: Lessons from 50 Years in the Cockpit
This episode explores human performance and aviation safety, contrasting airline
PAPod 573 - The Stability Trap: Why Safe Organizations Still Fail
Jay Allen interviews Todd Conklin about his new book, The Stability Trap, explor
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