Mistakes Are the Best Teacher

Why You Should Embrace Mistakes & Not Walk Away from Them

They happen. It's what you learn that's important.

People make mistakes. That's true in all walks of life, including in the perioperative setting. How a leader responds to mistakes can either reduce errors or lead to more errors. There’s little in-between.

Amy Edmondson, now the Novartis Professor of Leadership and Management at the Harvard Business School, researched hospital errors and discovered two truths. The first is where errors are unforgivable, there are fewer errors. That doesn’t mean they aren’t happening. It means they aren’t being reported and, as a result, corrections weren’t being made. Worse, if they can get away with it, people will hide their mistakes.

On the other hand, Edmondson found that units with strong transformational leaders have a lot of reported errors. That was because every error was used as a learning opportunity, so those errors were not repeated.

5 Ways to Help Your Team Learn from Mistakes

1. Believe the research.

Research shows punishments shortsighted and just doesn’t work.

Instead, people learn from exploration. They learn from figuring out what did and didn’t work. For many organizations, that's a different approach to how they are treating errors.

2. Understand the true cause.

When the first reaction to a mistake is to punish the nurse who made the mistake, the nurse is labeled as the cause. Take a look at the system or the process instead. If protocol wasn’t followed, is more education needed? If a wrong medication is administered, is there a problem with documentation? If the system is improved, the mistakes will happen again.

3. Take a positive approach.

Words like "mistake" and "error" are negative terms. Staff need to feel comfortable speaking up when they make or witness a mistake.

One way to help staff learn and grow is to put a place on the staff meeting agenda for learning from errors.

Since some staff may not want to admit making mistakes, keep it anonymous and consider providing a way for the anonymous sharing of information.

Take the aviation industry as an example. When pilots make an error, or come close to making one, they can write it up for a central database. This information is then used to improve training or fix system issues. Perioperative departments can offer something similar.

4. Spread the knowledge.

Many mistakes that occur in and around the OR are not exclusive to a procedure or specialty.

"This makes it possible to support the entire department," When you get people talking about what they learned from the mistake, it can help ensure the mistake doesn't happen again.

Education can be extended beyond the perioperative department. For a small hospital, there may be value in sharing the experience with other departments. For health systems with multiple facilities and many ORs, it would be great to see wider communication that helps as many people within the system learn from others’ mistakes.

5. Put down your guard.

If perioperative leaders want their staff to learn from mistakes, they must be willing to do the same. If a leader says they could never admit to a mistake, you have trouble. The mark of a transformational leader is to be open and vulnerable."

Slow Path to Change

Being open about mistakes is a shift in thinking and it doesn’t come easily. Changing a culture is a struggle but what’s important is leadership support.

Related Resources

Introducing: Leader Exchange

In this new, panel-driven webinar series from AORN Center for Perioperative Leadership, you’ll learn effective practices for leaders, from leaders. Topics address hard and soft skills and range from staff management to leveraging new technologies for patient safety and efficiency. Each webinar will provide the tools you need to excel in the many facets of perioperative leadership. See the lineup of monthly topics and save your seat at the first live session on Nov. 14. Register for the webniar.

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