From Mistake to Opportunity: Creating a culture where safety is valued

How do we create a culture of safety around reporting mistakes?

Morgan Goldsmith
September 23, 2020

Morgan worked in a variety of patient care settings before moving into medical device in 2013. Her journey led her to Stryker, where she now brings clinical insights to the product marketing team. In 2020, Morgan took a 2-month leave of absence to serve in a COVID field hospital during the height of the pandemic in New York City.

As Registered Nurses, we start our careers by taking an oath to advocate, care for and protect our patients. From the day I took that oath until the day I touch my last patient; I will always be humbled by the privilege and responsibility that comes with taking care of another human being.

Nursing is a special profession that provides many different types of roles, each with different dynamics. I began my career as a burn nurse, first for adults and then children. The incredibly complex care we delivered, high acuity of patients and the often-horrifying experiences that led them to us created an unbreakable foundation that developed my nursing skills and tested my resolve.  Watching burn patients recover and persevere over weeks and months was incredibly rewarding.

I later moved to an outpatient surgery center where I began in the Pre-Op and PACU before moving into the O.R. Though different roles and environments, I learned that the challenges presented in each were very similar.  Mistakes, whether at the bedside or in the O.R., were often the result of limited staffing, poor communication or a lack of coordination amongst the many people involved in delivering patient care.

Regardless of your unit or nursing specialty, we are humans and error is unavoidable.  We know every mistake that touches a patient is inexcusable – and rightly so. When a mistake happens and is reported, the nurse (or tech, doctor, therapist) is almost always written up. This has a negative impact on their morale and potentially on their career. The tragedy here is two-fold: it often puts blame on the person left trying to address a chain of systematic failures which led to the situation, and worse, it creates a culture with negative incentives to report mistakes in the future.

How do we create a culture of safety around reporting mistakes?

“In nursing school, we are taught to utilize “therapeutic communication” with our patients. When done well, it creates a relationship of mutual respect between the clinician and patient.  The goal is for the patient to understand their care plan and feel safe asking questions.  

As clinicians, what if we leveraged our therapeutic communication skills as we interact with each other? What if caregivers were encouraged, praised and respected for reporting mistakes and near-misses?  Think of the culture of safety accountability and responsibility this could create – a true pivot away from blame and towards a solution.

This is my why and it is the reason I’m passionate to work for Stryker today. Every day, I try to bring the insights of clinicians back to Stryker so we can develop the right solutions to mitigate the underlying problems before they can touch a patient or impact a nurse that is doing their best.

I think about my oath every day – and now with increased urgency – because I feel the obligation to care not just for patients, but for the clinicians around them.”

"Regardless of your unit or nursing specialty, we are humans and error is unavoidable.  We know every mistake that touches a patient is inexcusable – and rightly so."

[1] Pierce JS, Lacey SE, Lippert JF, Lopez R, FrankeJE. Laser-generated air contaminants from medical laser applications: a state-of-the-science review of exposure characterization, health effects, and control. J Occup Environ Hyg. 2011; 8(7):447-466.

[2] Effective dates: Colorado (May 1, 2021), Illinois and Kentucky (January 1, 2022), Georgia (July 1, 2022), Oregon (January 1, 2023), Minnesota (May 17, 2023), Louisiana (June 1, 2023), New Jersey (June 11, 2023), New York (June 14, 2023), Ohio (July 3, 2023), Missouri (July 6, 2023), California (October 7, 2023), Arizona, Washington, and Connecticut (January 1, 2024), West Virginia (March 22, 2024), Virginia (March 28, 2024).

[3] According to research by McKinsey & Company, by 2025, the United States may be short as many as 200,000 to 450,000 nurses needed to provide direct patient care.

[4] 2021 AORN Guideline forSurgical Smoke Safety.

This is a paid interview with Stryker nurse consultants, conducted on behalf of Stryker.