Errors as Opportunities
Reflection: Mistakes as Teachers
As a new nurse, I was helping care for a patient recovering from a motorcycle crash when I misapplied a wound dressing. At the time, I believed I had done everything right: I followed the physician’s orders and even asked another nurse for guidance. The next day, however, my nurse manager told me the medical staff had noticed it wasn’t applied correctly. That was difficult to hear, but it also revealed something bigger—neither I nor the other nurse truly knew the proper technique. Instead of seeing it only as my failure, I now recognize it as a reminder of how essential training and mentorship are. With stronger education on wound care, that situation could have been transformed from discouragement into a powerful teaching moment.
Another mistake happened when I crushed and administered a medication through an NG tube without realizing it wasn’t safe to crush. Neither error was intentional, but both moments stayed with me. While they initially left me feeling disappointed in myself, I now see them as valuable lessons. These experiences reinforced the importance of pausing, asking questions, and confirming understanding rather than assuming it.
The culture around mistakes matters a lot in healthcare. Errors should be treated as opportunities for learning, not reasons for shame. Looking back, my unit often focused more on confronting errors than on educating through them. That approach didn’t build confidence—it created hesitation. Over time, those experiences have shaped my belief that nurses learn best in an environment that encourages curiosity, reflection, and growth.
These experiences strengthened my resilience and reshaped how I look at errors. Instead of focusing only on what went wrong, I now ask what in the system made the mistake possible and how I can use my voice to advocate for safer practices. That perspective reflects the heart of a Just Culture—balancing accountability with learning and building an environment where errors are not hidden in shame but transformed into opportunities for growth and improvement (Albert & Pappas, 2025).
Errors vs. Failures: Why the Distinction Matters
In a Just Culture, it’s essential to understand the difference between an error and a failure. An error is a preventable mistake( i.e. giving the wrong medication) that represents a break from accepted practice (Dirty Medicine, 2024). Errors can be active, occurring at the bedside in real time, or latent, embedded in the system through poor communication, faulty equipment, or gaps in training.
Failure, on the other hand, happens when things don’t go as expected, even if the plan was followed correctly. A patient may not respond to treatment, or a carefully designed plan of care may fall short despite everyone’s best efforts. Failures aren’t about negligence; they reflect the complexity and unpredictability of healthcare.
For nurses, this difference matters because it shapes how we support each other. Errors point to where processes and training need to be strengthened. Failures call us to reflect, adapt, and grow without attaching blame. When we approach both with honesty and compassion, every outcome becomes an opportunity for improvement.
This distinction is critical: it shifts the focus from blame to a culture of safety, where mistakes are examined for what they can teach us rather than who can be punished. In that kind of culture, accountability is paired with learning, and growth is possible for both individuals and systems.
Just Culture in Action: The Power of Transparency
Leilani Schweitzer’s (2013) TEDx talk is powerful because of how she chose to use her voice after the tragic loss of her son. In an effort to let her rest, a nurse silenced the alarm on his monitor. When the alarms failed to sound at a critical moment, no one was alerted in time. Faced with unthinkable grief, Schweitzer could have chosen silence or bitterness. Instead, she chose honesty.
The hospital responded with transparency: they admitted what had happened, included her in conversations, and allowed her story to shape safety improvements. By speaking openly, she not only found healing for herself but also made care safer for countless other families.
Her voice is a reminder that transparency is more than a policy; it is a deeply human act. When leaders and caregivers are willing to tell the truth, even when it hurts, that honesty can transform grief into meaningful change.
Errors as Opportunities: The Paradox of Interruptions
Nursing is full of interruptions—alarms sounding, phones ringing, families with urgent questions, coworkers needing help. While some interruptions are essential for patient safety, many only serve as distractions. They raise stress levels and increase the risk of errors. I remember shifts where I felt pulled in five different directions at once—trying to chart, answer a call light, and pass medications simultaneously. Beth Boynton’s exercise hit home for me because it captured that exact reality. It highlighted how easily mistakes can happen when constant distractions break our focus on patient care.
The truth is, interruptions will always be part of nursing, but leaders can make a difference by setting the tone. It should be okay for a nurse to pause and say they need a moment to finish something safely. Too often, I’ve felt pressure to continue on without asking for that space. In a Just Culture, assertive communication should be expected. Nurses should feel supported in protecting their focus so patient safety always comes first.
Navigating Complexity: Ebright and the Swiss Cheese Model
Patricia Ebright’s ideas on stacking and peeking resonate with my nursing experience. Stacking is the constant reshuffling of a mental to-do list, while peeking is those quick checks on patients to decide whether to stay or move on. While these strategies eventually became second nature, I remember struggling as a novice nurse to know how to prioritize my mental list.
I believe it is essential to teach these strategies to new nurses because they bridge the gap between what is taught in nursing school and the unpredictable realities of bedside care. Stacking helps nurses remain flexible by continually reordering priorities as demands shift, while peeking trains them to notice subtle changes in a patient’s condition before they escalate. Together, these habits ease the overwhelm that new nurses often experience and add an extra layer of safety. Learning them early builds confidence, strengthens patient safety, and helps new nurses see complexity not as chaos but as the natural rhythm of nursing practice.
Ebright’s work also aligns with James Reason’s Swiss Cheese Model, which shows how errors happen when gaps in multiple defenses line up. Policies and protocols provide important safeguards, but they cannot anticipate every situation. In those moments, cognitive strategies like stacking and peeking act as flexible, real-time defenses that prevent problems from slipping through the cracks. They are the human layers of protection that strengthen the system.
Mandatory Reporting and a Culture of Safety
When I hear the words mandatory reporting, I understand why it incites fear. Too often, staff wonder what repercussions they will face. However, I’ve come to believe that healthcare workers shouldn’t feel intimidated after committing an error—because errors happen, even to the best of us. The point of reporting isn’t to punish; it’s to learn. Each report offers information that can highlight patterns, expose risks, and prevent harm from happening again.
For reporting to work, though, staff need to feel safe. Hospitals can’t just compile reports—they need to show how those reports lead to real changes. When leaders give feedback, separate human error from recklessness, and are transparent about improvements, mandatory reporting stops being a threat and becomes a tool for growth. That’s when it strengthens Just Culture: a space where honesty makes care safer for everyone (Dekker, 2017).
In a Just Culture, unreported errors can’t be fixed. Sandra L. Warner (2016), writing in Nursing Management, explains in her article “Productive Errors” that transformational leaders don’t ignore mistakes or bury them in blame. Instead, they use errors as opportunities to help their teams learn, adapt, and improve practice. This approach motivates employees to be accountable for their actions while also striving for excellence. When leaders respond this way, errors become catalysts for growth rather than moments of shame.
Moving Forward with Humility and Compassion
If my mistakes have taught me anything, it’s that humility and compassion are essential, for myself and for others. In healthcare, errors are inevitable, but the real measure of our culture is how we respond when they happen. We must be willing to admit when errors occur, and just as importantly, we need environments that meet honesty with support instead of judgment. In a Just Culture, every error becomes an opportunity for growth and safer care.
At its core, Just Culture is about education and awareness. Nurses can’t be expected to avoid every mistake if they aren’t given the tools, knowledge, and a safe space to learn. When errors are shared openly—not to shame, but to teach—they become lessons that spread across the team.
As a future nurse educator, I want to model this for my students. I want them to see mistakes not as failures but as starting points to pause, reflect, and grow. Leaders also have a responsibility to create a culture where speaking up and asking for focus is encouraged. That kind of environment protects both patient safety and nurse confidence.
Those early errors that once left me ashamed now feel like some of my greatest teachers. They remind me that nursing isn’t about never stumbling, it’s about building a culture where every stumble helps us walk more safely together. At the end of the day, we are all in this together.
References:
Albert, N. M., & Pappas, S. (2025). Quantum leadership: Creating sustainable value in health care (7th ed.). Jones & Bartlett Learning.
Dirty Medicine. (2024, July 20). Patient safety and quality improvement [Video]. YouTube. https://www.youtube.com
Ebright, P. (2007). Pat Ebright – Peeking [Video]. YouTube. https://www.youtube.com/watch?v=iFO4FDrEVBc
Ebright, P. (2007). Pat Ebright – Stacking [Video]. YouTube. https://www.youtube.com/playlist?list=PLB9950D3119BF557A
Schweitzer, L. (2013, April). Transparency, compassion, and truth in medical errors [Video]. TEDxUniversityofNevada. https://www.youtube.com/watch?v=qmaY9DEzBzI
Warner, S. L. (2016). Productive errors. Nursing Management, 47(1), 52–54. https://doi.org/10.1097/01.NUMA.0000475624.42736.ef
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