On March 25, 2022, most of the healthcare community was shocked and dismayed after learning that RaDonda Vaught had been convicted of criminally negligent homicide and gross neglect of an impaired adult following the 2017 death of Charlene Murphey. This case involved a combination of both active failures, including human errors and unsafe behavioral choices as well as latent failures within the organization. Regrettably, healthcare organizations tend to turn a blind eye to both risky systems and risky choices, believing patients are safe if bad outcomes—meaning harmful or fatal errors—do not happen to them. However, this type of error could happen anywhere given the current system vulnerabilities frequently found in hospitals. This recording gives an overview of the breakdowns in the medication-use process in this case as well as list examples of both active and latent failures. Discussion of organization’s responses to human error, at-risk behaviors and to those who suffer emotionally when the care they provide leads to patient harm (often referred to as second victims) is included. Also discussed are proactive ways to identify risk, including the use of error reporting programs and improving staff engagement to address unsafe practices before an error occurs. The program concludes with a discussion of effective risk reduction strategies to prevent harm to patients. Provider approved by the California Board of Registered Nursing, Provider number 12205 for 1 contact hour.