Part two of the RaDonda Vaught story examines what emerged after the event: investigation details, system design flaws, communication breakdowns, and the tiny timing error that mattered. RaDonda Vaught recounts how normalized overrides, software defaults, and organizational assumptions created conditions for failure.
The episode explores the chilling effects of criminalizing mistakes, the human cost across patients and providers, and the case for shifting from blame to system-focused learning and improvement.
PAPod 568 - PART ONE: Charged for a Mistake: The Nurse, the Error, and a System That Failed
In this episode, nurse RaDonda Vaught tells the detailed, context-rich story of
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
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.
