Carole Hemmelgarn

This week, we focus on the healthcare system, where failure is literally a matter of life or death.

This week, we focus on the healthcare system, where failure is literally a matter of life or death.

Some organizations felt like they had already achieved the patient safety mission. Others, it wasn't even part of their strategic plan.

Some organizations felt like they had already achieved the patient safety mission. Others, it wasn't even part of their strategic plan.

Some organizations felt like they had already achieved the patient safety mission. Others, it wasn't even part of their strategic plan.

And we will learn where on a spectrum to place every failure. From inexcusable.

And we will learn where on a spectrum to place every failure. From inexcusable.

And we will learn where on a spectrum to place every failure. From inexcusable.

The story of Carol Hemmelgarn's daughter is tragic, a hospital death caused by something other than the reason the patient was in the hospital. Unfortunately, that type of death is not as rare as you might think. Consider the case of Redonda Vaught, a nurse at Vanderbilt University's medical center.

The story of Carol Hemmelgarn's daughter is tragic, a hospital death caused by something other than the reason the patient was in the hospital. Unfortunately, that type of death is not as rare as you might think. Consider the case of Redonda Vaught, a nurse at Vanderbilt University's medical center.

The story of Carol Hemmelgarn's daughter is tragic, a hospital death caused by something other than the reason the patient was in the hospital. Unfortunately, that type of death is not as rare as you might think. Consider the case of Redonda Vaught, a nurse at Vanderbilt University's medical center.

In 2019, she was prosecuted for having administered the wrong medication to a patient who subsequently died. The patient was a 75-year-old woman who had been admitted to the hospital for a subdural hematoma, or bleeding in the brain. Here is Redonda Vaught testifying at her trial.

In 2019, she was prosecuted for having administered the wrong medication to a patient who subsequently died. The patient was a 75-year-old woman who had been admitted to the hospital for a subdural hematoma, or bleeding in the brain. Here is Redonda Vaught testifying at her trial.

In 2019, she was prosecuted for having administered the wrong medication to a patient who subsequently died. The patient was a 75-year-old woman who had been admitted to the hospital for a subdural hematoma, or bleeding in the brain. Here is Redonda Vaught testifying at her trial.

The medication that Vaught meant to pull from the Acudos machine was a sedative called Versed. What she mistakenly pulled was a paralytic called Vecuronium. Vecuronium instead of Versed.

The medication that Vaught meant to pull from the Acudos machine was a sedative called Versed. What she mistakenly pulled was a paralytic called Vecuronium. Vecuronium instead of Versed.

The medication that Vaught meant to pull from the Acudos machine was a sedative called Versed. What she mistakenly pulled was a paralytic called Vecuronium. Vecuronium instead of Versed.

Redonda Vaught was convicted of negligent homicide and gross neglect of an impaired adult. Her sentence was three years probation. You might expect a patient safety advocate like Carol Hemmelgarn to celebrate Vought's prosecution, but she doesn't.

Redonda Vaught was convicted of negligent homicide and gross neglect of an impaired adult. Her sentence was three years probation. You might expect a patient safety advocate like Carol Hemmelgarn to celebrate Vought's prosecution, but she doesn't.

Redonda Vaught was convicted of negligent homicide and gross neglect of an impaired adult. Her sentence was three years probation. You might expect a patient safety advocate like Carol Hemmelgarn to celebrate Vought's prosecution, but she doesn't.