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 589 - Failing Safely: Todd Conklin on Resilience, Recovery, and Real Work
In this episode, Todd Conklin joins Amir Shahzad to discuss human and organizati
PAPod 588 - Weak Signals, Big Consequences: The RaDonda Story
Hosts Todd and Brent discuss an upcoming restorative workshop centered on RaDond
PAPod 587 - Start in the Black: How Sleep Debt Impacts Safety
Host Todd Conklin interviews fatigue expert Mark Rosekind, PhD about his path fr
PAPod 586 - VUCA, Uncertainty, and the Case for Innovation
Todd Conklin discusses VUCA (Volatility, Uncertainty, Complexity, Adaptation) an
Got a question, press inquiry or idea you'd like to share? Contact us through the form below and let us know how we can help.
