The article below lays out the timeline of what occurred in the incident at Vanderbilt University Hospital, which lead to the trial of Nurse RaDona Vaught:
Just Culture () and stop at the line, are a couple of critical operational elements in our system.
Being that this is a very tough subject and there are many opinions, please focus on what we have learned and what can organizations do better to help avoid errors, knowing that we are humans caring for humans.