PreAccident Investigation Podcast PAPOd 560 - When Hospitals Criminalize Error: A Patient Safety Reckoning
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Aug 23, 2025 Lisa Zegan, a seasoned patient safety leader and former emergency room nurse, dives deep into the tragic 2017 Vanderbilt medication error. She emphasizes the dangers of criminalizing mistakes, arguing it stifles learning in healthcare. Zegan critiques how design flaws and billing pressures contribute to medical errors, advocating for a cultural shift towards transparency and systemic reforms. The conversation also touches on the fallacy of 'zero harm' and the crucial need for collaboration across hospitals to enhance patient safety. Zegan's insights shine a light on how we can transform healthcare for the better.
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Vanderbilt Wrong-Drug Tragedy
- A 2017 Vanderbilt medication error occurred when a nurse pulled the wrong drug from a dispensing cabinet and a patient died. The nurse reported the error, was fired, later charged, and found guilty of a lesser charge with probation.
Design Created Failure Pathways
- The medication cabinet design created new failure modes by requiring generic-name typing and enabling broad overrides. These design choices made it easier to pick a paralytic instead of Versed.
Blame Undermines Learning
- Criminalizing human error stops organizational learning and leaves systemic conditions unchanged. Punishing the worker preserves the brittle system and invites repeat harm.