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 596 - Incremental Safety Practices: Reductive vs. Inductive Safety
Todd Conklin reviews Erik Hollnagel’s new book "Incremental Safety Practices" an
PAPod 595 - Beyond Checklists: How Conversations Transform Safety Culture
Host Todd Conklin talks with Daniel Hummerdahl about his new book, An Invitation
PAPod 594 - Bridging Cultures: Safety, Migrant Workers, and the Heart of Agribusiness
Coming into this episode, Todd Conklin welcomes Al Thomson to discuss safety in
PAPod 593 - Young Voices, System Thinking: A Conversation on Safety with Mousa Yassin
Host Todd chats with Mousa Yassin about shifting safety culture from blaming ind
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