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 focus on improving safety culture.

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).

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.