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 567 - Open Questions 2025: From Metrics to Monitors — Rethinking Safety
Episode: an extended open Q&A from the Pre-Accident Investigation Conference in
PAPod 566 - Blame Stops Improvement: How Blame Silences Learning
Todd Conklin explores how blame shuts down learning and prevents organizational
PAPod 565 - Fear, FOMO & Fixing Safety: A Conversation with Brent Sutton
Todd Conklin and Brent Sutton discuss the short-term future of safety thinking—c
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.
