DescriptionThis opening presentation will consist of a discussion panel focused on the recent Radonda Vaught medication error case. This case was brought to the forefront in recent weeks after a nurse was convicted of negligent homicide following a medication error. The discussion panel will bring together a group HF/E experts to discuss the case, with a focus on systems thinking and implications for safety. Discussants will include Drs. Tony Andre, Yuval Bitan, Joseph Keebler, and Elizabeth Lazzara, and will be moderated by Ms. Kimberly Williams.