PreAccident Investigation Podcast PAPod 583 - When Normal Variability Breaks: The ReDonda Story
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Jan 31, 2026 Ann Lyren, a patient safety leader who works with pediatric hospitals to strengthen safety culture. She and others preview a Santa Fe workshop exploring how ordinary performance variability combined to cause a tragic case. They discuss charting contextual conditions, operational pressures like throughput, and cross-industry learning with practical tactics for identifying and responding to accumulating risks.
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Accidents Are Normal Variability
- Accidents are an unexpected combination of normal performance variability, not exotic failures.
- Todd Conklin emphasizes this as the core lens for learning from incidents like ReDonda's case.
ReDonda's Personal Moment
- Todd Conklin called ReDonda and she said "everything in my life has led up to this moment."
- He describes her excitement to meet the patient safety community and attend the workshop.
Tragic Yet Unexceptional
- The case is both tragically unique and remarkably typical in its causes.
- Ann Lyren notes that the more she learned, the more she saw familiar normal pressures and conditions at play.