On the evening of Sept. 30, Tennessee gave Christa Pike a dose of pentobarbital, then a backup dose. She did not die. Witnesses heard her breathing behind the curtain for close to an hour, and she left the prison in an ambulance instead of a hearse. A week later, her lawyers say she is conscious in a Nashville hospital, still shackled to her bed.

The Department of Correction’s first response was that it followed every step of its approved protocol. I spent my career in research and development, and I have read sentences like that in failure reports. When a process follows its procedure exactly and still fails, the procedure is the defect.