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PODCAST

PreAccident Investigation Podcast

The Pre Accident Podcast is an ongoing safety podcast conversation of Human Performance, Systems Safety, & Safety Culture.

government & organizations

All Episodes

18:37

PAPod 584 - How Pediatric Hospitals Cut Fatal...

PreAccident Investigation Podcast ·

2026/02/07

This episode tells the real-life story of how the Society for Patient Safety and a network of children’s hospitals used learning teams, proactive safety huddles, and simulations to reduce unplanned extubations in neonatal ICUs — cutting rates by 60% and preventing thousands of deaths.It covers the data, the frontline-led solutions, the narrowing of racial disparities, and an invitation to a small conference in Santa Fe to learn and share improvement practices.

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27:29

PAPod 583 - When Normal Variability Breaks: The...

PreAccident Investigation Podcast ·

2026/01/31

This episode previews a small workshop in Santa Fe where Todd Conklin, Ann Lyren, and guest ReDonda Vaught will explore a tragic patient safety case. They frame accidents as the unexpected combination of normal performance variability and discuss how to learn from such incidents.Listeners will hear about the meeting goals (March 31–April 1), opportunities to chart the event, and practical tactics for organizations to identify and respond to accumulating risks, with cross-industry lessons and a

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19:22

PAPod 582 - Accountability vs. Blame: Who Really Owns...

PreAccident Investigation Podcast ·

2026/01/24

Todd Conklin breaks down why accountability is an act of clarity, not blame or discipline, and why leaders and workers share responsibility for operational safety.He highlights the need to set roles before incidents occur, contrasts accountability with performance management, and announces a case-study workshop about Redonda’s Vanderbilt story in Santa Fe (March 31–April 1).

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18:19

PAPod 581- Measuring the Invisible: When 'Nothing...

PreAccident Investigation Podcast ·

2026/01/17

Todd Conklin explores why its so difficult to measure events that never happen and how traditional safety metrics can mislead organizations. He argues for focusing on metrics that validate safeguards and create desired outcomes rather than only counting accidents.The episode also touches on automation risks, the limits of frequency-based measures, and the need for better leading indicators and verification practices to keep systems safe even when nothing appears to go wrong.

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22:01

PAPod 580 - Start Right, End Safe: Building Better...

PreAccident Investigation Podcast ·

2026/01/12

Todd Conklin opens 2026 reflecting on why how we begin interactions and jobs matters more than we often realize. He uses stories from travel, aviation, and workplace examples to show that the start of an encounter often predicts its outcome.Conklin urges listeners to choose kindness, psychological safety, and deliberate planning—start the job when the right controls are in place—rather than beginning from hate, division, or aggression. He links these opening choices to organizational resilience,

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22:48

PAPod 580 - Start the Encounter Right: A 2026 Safety...

PreAccident Investigation Podcast ·

2026/01/10

In this episode Todd Conklin reflects on entering 2026 by urging listeners to focus on how we begin interactions—at work and in life. He explains how starting encounters from a place of respect, psychological safety, and proper planning increases the chances of ending safely and builds stronger, more resilient organizations.Practical takeaways include prioritizing pre-job readiness, shifting from compliance to capacity, and choosing kindness over division to improve culture, safety, and

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20:11

PAPod 579 - Stepping Back Almost 10 Years...Another...

PreAccident Investigation Podcast ·

2026/01/03

10. New Year’s Eve recap reflecting on a busy 2016 and the journey ahead into 2017.9. Host shares personal travel highlights and experiments in gratitude and generosity. 8. Announces a 2017 focus on seeking and affirming the fundamental goodness in people. 7. Reviews safety’s evolution: from compliance (Safety One) to safety-by-design (process safety). 6. Explains the current phase emphasizing human performance and managing variability rather than blaming workers. 5. Notes that incidents have

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2:50

PAPod 578 - Choose Gratitude: A Thanksgiving 2021...

PreAccident Investigation Podcast ·

2025/12/27

This special Thanksgiving 2021 episode shares one simple piece of advice: be grateful. It highlights the power of gratitude during hard times and encourages you to pause and appreciate what you have.When the world feels difficult, instead of meeting pain with pain, reflect on the people, support, and good things in your life. Gratitude helps you move forward with strength and perspective. Learn something every day, have fun, and be good to each other.

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23:23

PAPod 577 - Near Misses: The Unexpected Gift That...

PreAccident Investigation Podcast ·

2025/12/20

In this episode Todd Conklin uses the season of gift-giving to explain near-miss reporting: why it matters, how it shows whether controls worked or luck saved the day, and how organizations should respond with gratitude and learning—not punishment.

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27:33

PAPod 576 - From Continuous Improvement to Continuous...

PreAccident Investigation Podcast ·

2025/12/13

This episode shifts the safety conversation from continuous improvement to continuous capacity, introducing a practical dashboard of 10 operational indicators—five system capacities (exposure to unforgiving energy, robustness of safeguards, error tolerance/recoverability, detectability of variance, and recovery capacity) and five human capacities (sensitivity to variation, frontline insight, quality of learning, psychological safety, and supervisor load).Host Todd Conklin explains how these

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27:27

PAPod 575 - Vancouver Workshop: A Case Study in...

PreAccident Investigation Podcast ·

2025/12/06

Todd Conklin talks with Brent Sutton and Jeff Lyth about the upcoming HOP Workshop in Vancouver (Jan 28–29, 2026), centered on Redonda’s powerful firsthand story of patient safety, complex systems, restorative justice and resilience — lessons that translate across industries.Day one features Redonda’s narrative and panel discussion; day two focuses on hands‑on learning and innovation. Please attend, this workshop will be amazingly good for the soul! For tickets and details visit

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38:00

PAPod 574 - Margin for Safety: Lessons from 50 Years...

PreAccident Investigation Podcast ·

2025/11/29

This episode explores human performance and aviation safety, contrasting airline procedures with general aviation risks. Guests discuss building safety margins, the importance of planning vs. acting, and how economic pressures can erode resilience.Highlights include treating near-misses as learning opportunities, practical tips for pilots to increase recoverability, and real-world examples from naval operations and long-term flying experience.

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30:55

PAPod 573 - The Stability Trap: Why Safe...

PreAccident Investigation Podcast ·

2025/11/22

Jay Allen interviews Todd Conklin about his new book, The Stability Trap, exploring why even safe, stable organizations can fail. They discuss the "drive to zero," complacency, pressures on middle management, wearables and data, and lessons from aviation and the pandemic.The episode also covers how AI was used to reorganize the book’s ideas and help craft its ending, and offers practical reframes: treat safety as a capacity, see workers as system monitors, and retool systems to match capacity with

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29:08

PAPud 572 - The Stability Trap: Why Safety Success...

PreAccident Investigation Podcast ·

2025/11/15

Host Todd introduces his new book, The Stability Trap, and shares a sneak peek episode created with an AI-generated interview. The episode explores why organizations that appear safe can still experience accidents and how success itself can erode safety capacity.The discussion outlines the core ideas: safety as the presence of capacity, the three R's (redefine safety, reframe the worker, relearn investigation), and a five-stage practical blueprint for leaders, safety professionals, frontline

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29:38

PAPod 571 - Fail Fast, Learn Faster: A Conversation...

PreAccident Investigation Podcast ·

2025/11/08

In this episode Todd Conklin joins Jowanza Joseph to explore modern safety thinking: why human error is normal, how context shapes behavior, and why leadership response and system recoverability matter more than blame.They draw on examples from Los Alamos, AWS outages, SpaceX and everyday technology to show how organizations can design systems that tolerate failure and learn from it. Listeners will get practical insights into the five principles of human performance and how to build resilient

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38:33

PAPod 570 - Safety Differently Down Under: Todd...

PreAccident Investigation Podcast ·

2025/11/01

Todd Conklin joins the Brisbane Safety Differently Book Lab in Auckland for a lively discussion about leadership, accountability, and learning from everyday work. The group explores why safety is the presence of control, how leaders should respond after incidents, and why learning is the new currency of safety.Todd shares stories about writing his books, engaging with workers, and practical steps leaders can take to build confidence and capacity while fostering a learning culture.

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30:31

PAPod 569 - PART TWO: 11 Seconds: How a System, Not a...

PreAccident Investigation Podcast ·

2025/10/25

Part two of the RaDonda Vaught story examines what emerged after the event: investigation details, system design flaws, communication breakdowns, and the tiny timing error that mattered. RaDonda Vaught recounts how normalized overrides, software defaults, and organizational assumptions created conditions for failure.The episode explores the chilling effects of criminalizing mistakes, the human cost across patients and providers, and the case for shifting from blame to system-focused learning and

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44:31

PAPod 568 - PART ONE: Charged for a Mistake: The...

PreAccident Investigation Podcast ·

2025/10/18

In this episode, nurse RaDonda Vaught tells the detailed, context-rich story of a medication error at Vanderbilt that led to criminal charges. She walks through the events, system issues (including a recent EHR rollout and medication-dispensing delays), distractions, and decision points that contributed to the mistake.RaDonda describes how workarounds, unclear documentation in radiology, drug supply changes, and interruptions combined to produce a tragic outcome, and she explains the immediate

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51:18

PAPod 567 - Open Questions 2025: From Metrics to...

PreAccident Investigation Podcast ·

2025/10/11

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.

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22:46

PAPod 566 - Blame Stops Improvement: How Blame...

PreAccident Investigation Podcast ·

2025/10/04

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.

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744 results

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