By Esther Espuñes, EORNA President

Last week, I reflected on why measuring quality matters and how meaningful indicators can help us identify risks, understand variation and improve perioperative care. But data alone cannot create safer systems. We also need to learn from what goes wrong.

Adverse events, near misses and sentinel events are difficult moments for patients, families and healthcare professionals. Yet they can also reveal weaknesses in our systems that might otherwise remain invisible.

The Swiss Cheese Model reminds us that adverse events rarely result from a single failure. They occur when multiple layers of defence—people, processes, communication, technology and organisational systems—have weaknesses that align, allowing harm to reach the patient.

Learning from these events means looking beyond individual actions to identify underlying systemic causes. Root-cause analysis can help us understand not only what happened, but why it happened and which barriers failed.

But analysis is only the beginning. Findings must be communicated clearly to the teams involved, translated into practical solutions, and disseminated across the organisation so that learning becomes shared knowledge rather than remaining within one department.

We must also remember the second victims—healthcare professionals who may experience guilt, anxiety, loss of confidence or emotional distress following an adverse event. Supporting them is an essential component of a mature patient safety culture.

Throughout these past two months, we have repeatedly seen the pivotal role of perioperative nurses: protecting sterility, managing risk, contributing to quality improvement, interpreting indicators, identifying vulnerabilities and turning evidence into safer practice. Their clinical knowledge and proximity to patients, teams and processes position them not only as key contributors to safety, but as leaders of change.

Ultimately, the goal is not simply to learn from what went wrong, but to transform experience into safer systems, safer practice and a stronger culture of care.

Next week, I will bring these reflections together and explore a fundamental question: what does leadership for patient safety look like in the operating room, and what is the role of perioperative nurses in leading it?