Errors as Opportunities

Part of the human experience that comes with being born into a fallen world entails hardship and struggle. It’s what we do with those hardships that defines us. While we tend to do everything we can to avoid hardships and other difficult experiences, these are actually the types of moments that create the most room for growth. The same is true in healthcare. Struggle is inevitable. Our response to the struggle plays a crucial role in whether we let it break us or whether we grow from it. I have experienced this growth in light of struggle firsthand in my work as an emergency department charge nurse. There is one particular stretch of 3 shifts that comes to mind here. I had only been a charge nurse for a couple of months. It was a weekend in the middle of summer. During the first shift, we had two young MVA patients come in, both of which passed away. The second shift, we had a maternal arrest in which the mom and baby both passed away. During the third shift, between 3am and 4am, the time-block in which we have the fewest number of nurses on shift, we had a cardiac arrest that ended up passing away, as well as 3 level 1 trauma patients that all ended up intubated within the next 45 minutes. To end that shift, we had another cardiac arrest come in through triage. She also passed away. 6 patients lost their lives that weekend. Similar to everyone else that worked those three shifts, I left feeling mentally, emotionally, and physically exhausted. As the leader of the department, even though the outcomes were very much outside of my control, I felt like I should’ve done something more. 

Reflecting on those three shifts now, I can see that they did not represent inadequacy on my part; rather, they became an important period of growth for me. Being brand new to the charge nurse role, I had set the unrealistic expectation for myself that I should always be able to make things better, that I should somehow stop my team from ever having to encounter difficult shifts or other hardships. That string of shifts taught me that being an effective leader doesn’t entail having the ability to control everything. Sometimes, despite having a wonderful team, the outcome isn’t what anyone hoped for. Since those shifts, I’ve come to understand that my responsibility as a leader is not to try and prevent hardships for my team; rather, it’s to help guide and support them through those hardships when they arise. I could have allowed those feelings of failure and inadequacy after those three shifts shut me down and convince myself that I was a poor charge nurse, or I could reflect on the experience and learn from it. I chose the latter. By doing so, I came to realize that failure or an unsuccessful outcome doesn’t necessarily mean that something wrong has been done; actually, failure can happen when no error has been made at all. 

Error and failure are not synonymous. As stated by Albert and Pappas (2025), “failures need to be recognized as unsuccessful without bad intent, and errors need to be recognized as deviations from accepted practice that need to be corrected” (p. 338). I think the distinction between failure and error is especially important in healthcare because an undesirable or unsuccessful outcome doesn’t necessarily mean that an error occurred. For example, patients can pass away even when the healthcare team taking care of them does everything right. This was important for me to realize when reflecting on the three shifts I mentioned above. Although the patient outcomes were unsuccessful and undesirable, the team of nurses and doctors that took care of them did everything they could to save them. Errors, on the other hand, arise when someone veers away from an established protocol or process. Errors need to be corrected so that they don’t happen again. At this point, it’s important to note that errors should not necessarily lead to punishment of a single person. Oftentimes, errors are the result of system flaws.

While there is a time and place for punishing, or even terminating, certain staff members, it’s usually more effective to look at errors on a larger scale. According to Boysen (2013), “an individual may be at fault, but frequently the system is also at fault. Punishing people without changing the system only perpetuates the problem rather than solving it” (para. 2). Here comes to mind a situation one of my nurses encountered about a year ago. One of our brand new nurses in the ER took over caring for a patient that was transferred to our facility for a STEMI. The patient ended up not going for an emergent heart cath because he had received thrombolytics at the previous hospital, his EKG was back to normal, and he was chest pain free. He was started on a heparin drip with the plan to admit to our heart unit for the night and get the cath in the morning. The cardiologist had entered all of the routine pre-cath lab orders they normally place. One of those orders was to discontinue the heparin drip prior to cath lab. My nurse misunderstood that order and ended up shutting the heparin off as soon as the order came through. Approximately an hour later, the patient started to have chest pain again and a repeat EKG showed STEMI. The patient was taken for an emergent heart cath. Our new ER nurse unintentionally made an error that led to a patient being harmed. While she was spoken to and educated on her wrongdoing, more investigation of the error led to the realization of a system problem. It wasn’t just her that had misunderstood the orders. Many others said they were also confused by the orders whenever they came through. The wording of the orders has since been changed. This change in process resulted from the just culture that we have in our hospital. As explained by Puno (2015), in a just culture, “human error is met with understanding and reporting the incident is encouraged to identify variables behind the error to collectively improve system processes” (10:18). The situation with our new nurse and the STEMI patient showed me why the manner in which an error is handled is so important. By not just focusing on punishing a single individual and instead looking at things from a wider picture, a flaw in the system was able to be identified and corrected so that the same thing does not happen to any other patients. Errors are valuable learning opportunities. Examining why an error occurred on a system-wide level provides an opportunity to make healthcare safer. 

This broad approach to error based on a just culture connects closely to the science of human factors. As stated by Medisense MedEd (2017), “human factors describes how we interact with everything in the workplace. The physical environment with equipment and with the processes of care that set out how we’re supposed to do things” (1:30). With that, looking at error through this lens of human factors entails considering the conditions surrounding an individual when they’ve made an error. With my new nurse, it would have been easy to jump to conclusions and blame her. By looking at things on a deeper level, however, we were able to see that there was a weakness in the system and process of care for our STEMI patients. Taking this idea a bit further, the science of human factors also helps to see latent errors within the system. While active errors arise from an action that’s taken by an individual, latent errors come about from an underlying system flaw (Dirty Medicine, 2024). While my new nurse made an active error by turning the heparin off, it helped to reveal the latent error, a mistake waiting to happen, of a poorly worded and confusing order. Identifying both the active and latent error helped us to correct not only the individual that made the initial mistake, but also the underlying system flaw that led to the mistake. As a charge nurse, situations such as this remind me to remain curious and refrain from placing blame. The emergency department is a busy, complex environment. Factors such as level of nursing experience, staffing, acuity, and workload can all influence an individual’s performance. While these factors do not eliminate the need to hold ourselves and our team accountable, recognizing them can help us find opportunities to prevent future errors from being made. Creating a just culture is about finding a balance between holding individuals accountable and realizing when certain aspects of the system surrounding them need to change, such as staffing. 

Note: This image was AI-Generated

Staffing is a factor that has the potential to have a significant impact on both healthcare staff and patient safety. Since becoming a charge nurse, I’ve realized that the idea of staffing encompasses a lot more than just the number of nurses that are scheduled on any given shift. The experience level of the nurses working, as well as patient volume and acuity, all play a role in staffing. This is especially evident in the emergency department, where volume and acuity can change in the blink of an eye. The story of the three shifts I mentioned earlier demonstrates the unpredictability of an emergency department. During the third shift, multiple critical patients arrived at the time of night in which we typically have the lowest number of nurses working. While the staffing was fine for a “normal” shift, it quickly became inadequate and unsafe when the cardiac arrest and trauma patients all arrived within an hour of each other. Experiences such as that night taught me that staffing is not merely a numbers game. The amount and complexity of the work being tasked to the nurses at any given time also needs to be considered. Taking the discussion further, it’s important to realize that the level of experience amongst team members on any given shift is just as important as the number of people scheduled. Newer staff members tend to need a lot more support and guidance than the more seasoned staff members. As a charge nurse, I’ve learned that having the appropriate number of nurses scheduled for any given shift doesn’t necessarily mean I have the appropriate mix of staff members. One way by which I attempt to account for the mix of staff I have on any given shift is by being intentional when making daily assignments. Rather than just going right down the list and filling people in as I go, I attempt to place both new and seasoned nurses on the same wing. I don’t send novice nurses to triage, nor do I put them in a float role. Even though I do the best I can to create staffing plans that are safe for my staff and our patients, the unpredictability of my department means that staffing needs can change rapidly. It’s my responsibility to help my department adapt on the fly, shifting my staff and resources around as needed. While it’s impossible to predict what’s going to happen on any given day in the emergency department, being able to adapt to its constantly changing needs helps me to create an environment in which my team is better equipped to provide safe care. When errors do arise, staffing should be one of the many factors that are considered when analyzing the circumstances that led to the event. While an inadequate volume of staff, inappropriate mix of staff experience, or an unusually high workload doesn’t excuse errors, factors such as these can sometimes help to explain why an error occurred and can also reveal room for improvement. 

In summary, both the hardships we encounter and the errors we make have the potential to become opportunities for growth. Looking back on that string of three difficult shifts, I realize that I learned far more from those shifts than I would have if everything had gone according to plan. The same goes for errors in healthcare. If we look beyond the surface and consider the systems, processes, and circumstances surrounding any error, we become better equipped to improve things for the future. As I continue to grow as a leader, I hope to create an environment in which my team feels safe owning up to their errors so that we can work as a team to make our hospital a better, safer place for both patients and staff. We may not be able to prevent every hardship or error in healthcare, but we can choose what to do with them when they arise. Ultimately, it is the way in which we respond to difficult moments that determines whether they will become moments of growth.

References

Albert, N. M., & Pappas, S. (2025) Quantum leadership: Creating sustainable value in health care (7th ed.). Jones & Bartlett Learning.  

Boysen, P. G., II. (2013). Just culture: A foundation for balanced accountability and patient safety. The Ochsner Journal, 13(3), 400-406. https://pmc.ncbi.nlm.nih.gov/articles/PMC3776518/ 

Dirty Medicine. (2024, July 20). Patient safety & quality improvement [Video]. YouTube. https://www.youtube.com/watch?v=oU5m5rQIHC4 

Medisense MedEd. (2017, October 10). Human factors: A quick guide [Video]. YouTube. https://www.youtube.com/watch?v=aGZz3w5Hy8Y 

Puno, G. (2015, October 18). Principles of high reliability organizations within healthcare institutions [Video]. YouTube.