In this session, we will analyze the groundbreaking case of nurse RaDonda Vaught, who was criminally charged for a fatal medication error at a massive healthcare system described as a "bizarre Frankenstein".

This discussion goes beyond individual mistakes to explore how context-rich system failures set workers up for disaster. We will dissect the numerous design flaws that contributed to the tragedy and the normalization of workarounds.

And understand why the decision to criminalize this human error creates a dangerous "chilling effect" that destroys psychological safety and squelches learning across the entire industry. Learn how to shift the organizational dialogue toward a restorative approach, focusing on fixing the complex, highly adaptive systems in which workers operate rather than blaming individuals.

And how this links back to Todd Conklin’s latest book, “The Stability Trap”, when organizations see safety and reliability as "a thing you achieve" rather than a capacity that must be continuously monitored, funded, managed, and improved.

HOP's reach is truly global. From humble beginnings to mainstream markets, organizations around the world are seeing the value and rewards of operational excellence. When we see workers as the solution and not the problem, we find the opportunities to learn and improve safety, quality, and operations.

Todd Conklin will discuss the stability trap, the trade-off between safety capacity and additional production and operational efficiency, and when organizations see safety and reliability as "a thing you achieve" rather than a capacity that must be continuously monitored, funded, managed, and improved. 

In these sessions, we will explore how organizations from Canada, New Zealand, Australia, and the United States are making a difference by putting HOP Into Action. We also look at the future of HOP and the role of innovation in operational learning in areas of organizational waste, the emergent risk of tacit knowledge as workers retire, why making work the right way and the easy matters, and how Human Centric AI, where people are the decision makers, is important as we innovate.