PreAccident Investigation Podcast

RaDonda Vaught, a registered nurse at Vanderbilt, shares her harrowing experience of a medication error that led to criminal charges. She delves into systemic issues surrounding a new EHR rollout and urgent workarounds that contributed to the tragedy. RaDonda recounts the pressure of a time-sensitive request and how distractions at the dispensing cabinet led to a misadministration of a paralytic instead of the intended medication. This candid reflection highlights the complexity of healthcare systems and sparks critical conversations about patient safety.

Episode: an extended open Q&A from the Pre-Accident Investigation Conference in Santa Fe covering big-picture safety topics. Speakers discuss the limits of traditional metrics, the power of real-time monitoring, shifting focus from managing risk to maintaining control, validating controls in the field, learning teams, contractor relationships, and prioritizing high-information events. Anecdotes and practical guidance illustrate how organizations can learn without blame.

Todd Conklin explores how blame shuts down learning and prevents organizational improvement, arguing that blaming individuals creates a chilling effect that blocks thousands of future learning opportunities. He connects blame to misunderstandings about human error, emphasizes psychological safety, and urges leaders to ask "what failed" before asking "who failed," while sharing personal anecdotes and reflections.

Brent Sutton, a safety and organizational resilience expert, joins Todd Conklin to explore the future of safety thinking. They discuss the decline of lean and TQM, how commodification stifles innovation, and the vital role of weak signals in fostering resilience. The conversation takes a lighthearted turn with breakfast burritos and debates over cheese, but the core message emphasizes the need for small, 'safe-to-fail' experiments and leaders' responsibility to navigate workplace complexities. Staying curious about evolving safety practices is key to preventing stagnation.

Recorded live at Meow Wolf in Santa Fe, this episode features a wide-ranging conversation between Todd and Andy Baker about learning, safety culture, and leadership influence. They dig into HOP and related safety approaches, debate top-down versus middle-out change, discuss the importance of language and unlearning, and explore how to turn belief into practical skill and behavior. The episode offers real-world insights on piloting change, engaging leaders and middle managers, and learning from others who have adapted these ideas in novel ways.

Tiny Todd Conklin joins the No Way Out podcast to explore Human and Organizational Performance (HOP), high-reliability organizing, and how safety emerges from complex systems rather than individual mistakes. They critique traditional investigations, surveys, and risk matrices, and discuss practical ideas for building capacity, worker agency, psychological safety, and resilient operations.

The discussion tackles the alarming issue of children left in hot cars, emphasizing that such failures are often unintentional. It encourages a cultural shift towards understanding and implementing preventative measures, like technology and visual reminders. Strategies to foster safety awareness replace blame, prioritizing system-level changes. Additionally, there's a look at generational differences in workplace ghosting and the evolving challenges employers face in hiring, spotlighting the need for mutual understanding in the workplace dynamics.

Lauren Mooney, author of 'High Reliability in Action,' joins the discussion to unveil how High Reliability Organizing (HRO) concepts can be practically applied. She shares her unique 'Speaking In' approach and introduces nine guiding questions for fostering safety. The conversation humorously dives into animal avatars, highlighting traits like humility and curiosity that can transform teamwork across industries. Mooney emphasizes leadership's pivotal role in creating a safety culture and adapting to challenges, especially in high-stakes environments like healthcare.

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.

In a dynamic discussion, Tom Krause, founder of Behavioral Science Technology and a pioneer in behavioral-based safety, shares insights on the evolution of safety leadership. He emphasizes how leadership decisions directly shape workplace safety culture and outcomes. The conversation touches on the relevance of W. Edwards Deming's principles and critiques traditional safety models. They explore the crucial link between leadership and organizational culture, alongside the exciting yet risky intersection of AI and safety practices. Krause's transformative ideas illuminate the future of safety leadership.