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Good People vs Poor System Design

This week I spoke to a group of business leaders about psychological safety. The title of my talk was ‘Listen Up -Speak Up: Saving Lives and Businesses’. It’s not a dramatic or click-bait title – it really is true.

For all that I talk about psychological safety and the importance of leaders creating safe and happy work environments for their employees (as well as themselves – I want you as a leader to be happy and at peace with your decisions too!), sometimes I’m very saddened to be reminded of just how much is yet to be done.

Those of you who have completed my R.E.A.L. Leadership programme may remember me speaking about nurse RaDonda Vaught who (like me) made a medication error. Unlike me, her patient very tragically died.

She was funnelled into making the mistake by multiple system design failures and by following the workaround steps that the hospital had e-mailed to all staff. These workarounds were so common that in fact 20 such workarounds had been applied in this patient’s medication in the previous 3 days. This is a multi-layered case (as they all are) but RaDonda has made it clear that she takes accountability for her medication error. She has repeatedly expressed her remorse and horror that her patient died.

A year after the event she was arrested. Her trial went ahead last month and to the horror of patient safety advocates and nurses all over the world she was convicted of criminal charges. Her sentencing is scheduled to take place on 13th May.

My LinkedIn posts about it have gathered some attention which you can see here.

RaDonda did the right thing in reporting her own error immediately through the correct channels and to anyone who would listen. The hospital hid the error, told the patient’s family that she had died of natural causes, later negotiated an out of court settlement on condition they don’t speak publicly about the case, and never reported the error to local and federal authorities which they were legally obliged to do under the Health Data Reporting Act of 2002 (US).

Who in their right mind would report their own error now?

This is one of many articles that summarises why patient safety advocates, nurses and professional bodies are dismayed at RaDonda's conviction.

This is the petition to sign if you feel the same.

Until next time, take care,



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