Join Alliance members from Oregon Health and Sciences University as they walk through the case of Tennessee nurse RaDonda Vaught who was recently convicted of criminally negligent homicide. The presenters will explore the facts of the case and use a patient safety lens to understand what systems factors may have contributed to a medical error resulting in the accidental death of a patient under her care. Finally, they will use a Just Culture framework to analyze how systems respond to human errors and how the medical community can create a safer environment for patient care and for health care workers.