Errors as Opportunities

            I really enjoyed Anna Voskamp’s blog post regarding her Secret to Parenting and the importance of allowing the struggle. I took some screenshots to make sure I remember that sound advice while raising my own young children. I’m a bit more of the anxious and worried parent than my laxed husband, so this quote really resonated with me. “Once fear grows, it becomes contagious. And once it becomes contagious, it can limit the scope of life. (Voskamp, 2018)”

In my previous blog post I discussed my struggles with the first unit I worked on as a new graduate nurse. Though I was so excited to have my first big girl job, I struggled with the “mean girls club” culture that was prevalent throughout the department. I would dwell on any criticism given by my preceptor or her friends. It was mostly because of how the criticism was given, not kind and supportive, just demeaning and condescending. I really don’t want to believe that this was a right of passage to feel belittled as a new graduate nurse, because as I became seasoned, I made sure I only provided supportive feedback and lessons to be learned from every situation. Looking back, I could see that these hardships made me a stronger nurse and I definitely made sure to not make the same mistakes made all those years ago! I used those hardships as pillars to ensure that I was not that kind of preceptor to the new nurses who trusted me with advice and guidance. With that, I would have to agree with the quote of “your best teacher is your last mistake.” I can still clearly remember telling my patient that the social workers were filing a petition with the courts to get his kids taken away because of his instability and history of reckless behavior. I thought I was doing the right thing by being honest and upfront, but I didn’t realize that on an acute inpatient psychiatric unit I needed to make my team aware so that we could approach this type of news with supportive back up. As a result, the patient went into an angry outburst and started punching at our sally port double doors, breaking those down, and luckily was stopped by police before getting off the locked unit. He ended up in our seclusion room until he was able to calm down and I felt terrible for causing the chaos due to my lack of inexperience as a psychiatric nurse. All I can say now is any type of remotely bad news is only shared with the patient once I’ve got a solid plan in place with my team of nurses. 

Great leaders will use errors as an opportunity for improvement and a way to learn from the mistakes made to better ourselves for the next patient. Leaders also evaluate a need for a change process in order to strengthen the system from preventing similar mistakes from occurring again (Albert et al., 2020). I was so refreshed when I transferred to my current hospital. I could tell my boss was enthusiastic, energetic, and positive. She allowed her employees to grow in their career and she highly valued process improvement efforts. If errors occurred, she would be the first one looking for volunteers to make the changes needed to close up the gaps in the Swiss Cheese!

            This was a vast difference from the hospital I had just left, the one where I had been a new graduate. That leader made sure any errors were shared amongst her clique of nurses through similar means of high school gossiping. There were never any wider discussions for improvement, simply just blaming the person on the end of the mistake. There were so many missed opportunities because that leader failed to value her frontline staff equally. The key differences with these leaders are the maturity to see that any error is an opportunity for growth whereas the other leader looked at an error as pure incompetency. As a leader I strive to always look at the near misses/close calls as ways to mitigate our risks and make the improvements necessary to prevent future incidents. If we had an adverse event reach a patient, I would never use that against an employee, I would ensure that Just Culture were used to look at wider system failure points, much like what happened in the video Annie’s Story. Unfortunately, Annie was immediately blamed for an error when in fact it was an error related to a faulty glucometer (MedStar Health, 2014). Had another nurse not made a similar mistake, she might’ve still been the one to blame in this situation! That type of stuff never makes a nurse feel good!

                My personal approach to Just Culture is to always look at the level of risk involved with the error. Was it pure human error? Was it risky? Or was it completely reckless? Could the error actually be malicious or due to impairment? From there I like to take in the number of times these errors are happening. For example, if there are numerous human errors, then perhaps there is a system issue going on. The organization is responsible for ensuring that system errors are managed and aid in developing the trust of the employees. The employees will not fear that they will automatically blamed (Albert et al., 2020).

              There is so much we have yet to learn from other industries and I truly believe the healthcare industry can get there. I’ve seen other webcasts from Dr. Gawande and I really enjoy his wisdom and comparisons to make healthcare not seem like we have an excuse for why we do things. The most insightful points were how he compared the use of checklists in the aviation and skyscraper construction industry. He referred to the checklists forcing humility, teamwork, and discipline (TED, 2012). 

Albert, N. M., Pappas, S., Porter-O’Grady, T., & Malloch, K. (2020). Quantum Leadership:

Creating Sustainable Value in Health Care: Creating Sustainable Value in Health Care.

Jones & Bartlett Learning.

MedStar Health. (2014, March 19). Annie’s Story: How A System’s Approach Can Change Safety Culture [Video]. YouTube. Retrieved January 24, 2023, from https://www.youtube.com/watch?v=zeldVu-3DpM&feature=youtu.be

TED. (2012, April 16). How do we heal medicine? | Atul Gawande [Video]. YouTube. https://www.youtube.com/watch?v=L3QkaS249Bc&feature=youtu.be

Voskamp, A. (2018, June 18). A Secret to Parenting that No One Tells You: The Strength is in the Struggle. Ann Voskamp. Retrieved January 24, 2023, from https://annvoskamp.com/2016/09/a-secret-to-parenting-that-no-one-tells-you-the-strength-is-in-the-struggle/