PAPod 569 - PART TWO: 11 Seconds: How a System, Not a Nurse, Failed
Episode 932
PreAccident Investigation Podcast
The Pre Accident Podcast is an ongoing discussion of Human Performance, Systems Safety, & Safety Culture.
Show Notes
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.
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