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 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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