Good systems learn from mistakes

Pam Simmons Guardian

Jodi was nine and one of five children. In total there had been over 40 child abuse notifications made about Jodi and her siblings. On their own the notifications were relatively minor. It was the pattern that told the story. When Jodi was admitted to hospital with a serious injury, people were angry that nobody had intervened before now. Everyone was looking to blame somebody.

To state the obvious, child protection is a seriousb usiness with weighty responsibilities. It is highly contested and there are few absolutes. It is a ‘high hazard’ environment where mistakes or oversights have a big impact for someone.

There are other high hazard environments, such as public transport, hospitals, mining, aviation, armed conflict and family law, to name a few. Some systems do better than

others at minimising the incidence and impact of mistakes.

Two international experts on human error and safe systems are Marilyn Rosenthal at the University of Michigan and Jim Reason at the University of Manchester. They make comparisons between aviation and health systems pointing to the success of the former in accepting that human error will occur and constructing a mostly sound system

of checks against error. Health systems do this too, to a greater or lesser degree, but it is a more ‘personal business’ with the health consumer playing a key role in safety. In health systems there is also a greater, and largely unhelpful, tendency when errors occur to blame the individual.

The same comments could be made about the child protection system. It is a highly personal business and we do tend to look to blame somebody. Bad parents, bad child, bad social worker or bad carer. Wrong court judgement, wrong assessment, wrong school or wrong choice. This is not always misplaced but it rarely provides a complete picture of what led to an incident or error in judgement.

So, what makes a good system with low incident rates and successful correction for mistakes?

Clearly, employing good workers and providing them with ongoing skills development and reward for good work is a start. Maintaining a healthy workplace and work hours is another. But good workers make mistakes too. Every good worker has. In most circumstances we don’t want to lose good workers because of a mistake, but we do want the wrong done to a person and its impact to be well acknowledged.

A good response to a mistake is to report it, admit it and apologise. But few people will do that if they expect to be hung out to dry.

What happens when we look to lay blame? Everyone keeps their head low, hopes someone else made a bigger mistake, searches for justification to support their judgement, and bunkers down until the storm passes. Most also continue to feel bad.

A good system is analytical and responsive. It will encourage the reporting of mistakes, help put things right, avoid blame, examine the mistake or incident closely and look at how the system should change to minimise the chance of it happening again. It should provide the checks and balances against escalation or repetition. It must also of course deal fairly and decisively with ongoing poor performance.

Any number of things could have gone wrong in Jodi’s case. The data system was inadequate and the notifications weren’t linked, there was high turnover of staff so no one made the connections, the notifiers expected that someone else would take responsibility, staff were intimidated by threats from the family or there were too many more urgent matters ahead of this one. Jodi should have been better protected. She wasn’t. We owe her an apology and assistance to recover. We ask why and we talk to everyone involved, without blame but looking for answers.

Dismissing a mistake or oversight as ‘just the system’ is also not useful. As said, child protection is a personal business and relies heavily on human interaction and

communication. A bad day can be a gravely bad day. Good workers will recognise when they are in a high risk situation. It may be the seriousness of the matter, the

difference of opinion, their personal feelings about one of the people, their tiredness and state of mind. They may start to look at something through a single lens and

recognise only the evidence that supports their view or recommendation. Good workers will seek help and good systems will have it.

There must be a way of attending to problems that accepts fallibility and is not shaming to people who talk about their mistakes. This will also support a professional culture that is consumer centred and will acknowledge the hurt done.

There are more external checks in the child protection system in South Australia now – Child Death and Serious Injury Review Committee, Health and Community Services

Complaints Commissioner, the Guardian for Children and Young People. There are also internal checks, the Adverse Events Committee, the Special Investigation Unit, and the Customer Relations Office. The more significant response though will come from deeper in the system – at the agency level where the services are provided. And the answer does not lie in increased regulation or scrutiny but in safety to report, admit, examine, review and change. It also of course lies with compassion and empathy.

Human error and health systems are discussed in the work of James Reason, Emeritus Professor of Psychology, University of Manchester in the U.K. who has written books

on absent-mindedness, human error, aviation human factors and on managing the risks of organizational accidents. Read more of his ideas in an interview at Marilyn Rosenthal, Professor of Sociology at the University of Michigan, has researched extensively on why doctors make mistakes.  Two of her books are Dealing with Medical Malpractice: The British and Swedish Experience and The Incompetent Doctor: Behind Closed Doors.

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