Fifteen minutes into the session, Belinda notices bruises on Brad’s forearm. When she asks how he got the bruises, Brad walks out of the clinic. Belinda does not know what to do. She waits outside Dr. Bledsoe’s office until his last patient leaves at 5:00 PM and then tells him that she suspects Brad is the victim of physical abuse. Dr. Bledsoe tells Belinda that he is unconcerned; he has known Brad’s parents for years. Belinda senses that Dr. Bledsoe thinks she is overreacting, but she persists. Dr. Bledsoe snaps at her, and then apologizes, explaining that he is tired. He promises to meet with Belinda on Monday to discuss her concerns. He then asks her to close the door behind her and returns to writing his notes. The clinic secretary, who is tidying her desk, sees Belinda leave Dr. Bledsoe’s office, and noticing that Belinda looks distressed, asks her what is wrong. Belinda blurts out her concern about Brad, wondering aloud if she should go over Dr. Bledsoe’s head and report her suspicions of abuse, and if so, to whom. Belinda asks if the other social worker is available, and the secretary informs her that he has gone home for the day. The secretary tells Belinda not to worry. She is certain that Belinda has done her job by informing Dr. Bledsoe. That night, Brad’s mother brings him to the emergency department in a neighboring suburb. He has a broken arm, and the triage nurse suspects abuse because Brad lowers his head and remains silent while his mother, who seems anxious, explains that the fracture occurred when Brad fell from a swing in the backyard. The triage nurse asks Brad’s mother to wait while she escorts Brad to an examination cubicle. When queried by the resident physician who examines him, Brad states that he tripped on the front steps of his house. While Brad is being examined, the triage nurse leads his mother to the small conference room where meetings with families are held. As Brad’s mother takes a seat, she informs the triage nurse that Brad met with a social worker (Belinda) earlier that day. The resident physician is waiting in the hall when the triage nurse exits the conference room. The resident physician tells her Brad’s divergent version of the injury and describes the yellowing bruises on Brad’s arm. The triage nurse pages the hospital’s social worker, Judy, to the emergency department. Judy is an experienced social worker. The triage nurse privately informs Judy of her suspicion, the conflicting stories, and Brad’s afternoon appointment with Belinda, and then introduces Judy to Brad. The boy turns his head to the wall. Judy goes to the family conference room and meets Brad’s mother. When Judy asks if she is concerned about her son, she almost immediately breaks into tears and informs Judy that her husband has been abusing Brad, both verbally and physically, over the past year; the beatings have escalated in frequency and intensity over the past month. Brad’s mother feels unable to protect her son and fears for her own safety. Judy alerts Child Protective Services and calls the women’s crisis center. She then makes a highly critical report of Belinda to the clinical director of In the language of human factors, Belinda and Brad’s encounter occurs at the sharp end, that place where weaknesses in the system of an organization come together to produce harm. As a mental health professional, Belinda is accountable for contacting Child Protective Services if she suspects or knows of child abuse. Her failure to do so is potentially an active failure (an operational error at the delivery level of the organization) and stems from inaction and faulty decision making (mistake). However, given her lack of experience and as a recent graduate of her master’s the substance abuse clinic. Case Study 1: Discussion
program, it is understandable that a considerable gray area exists in this clinical situation. Being unlicensed, Belinda necessarily must rely on supervision to manage cases and guide decision making. Numerous latent failures (hidden factors rooted in the work processes of the organization) facilitate this systemic error. These include an unmanageable caseload that most likely causes distraction and fatigue, inadequate supervision for an inexperienced worker, and a poorly communicated policy for reporting suspected abuse (if such policy exists at all). Decisions made at the blunt end, that is, by external forces and management, might include diminished state funding and resulting organizational budget cuts, which in turn produce an overworked staff. In a culture of blame, human error is accepted as the sole cause of a sentinel event. Clinicians are held accountable for mistakes, and all learning stops. Error-prone conditions remain hidden in the system, lying dormant in broken work processes, waiting to produce yet another disastrous event. In this case example, Belinda has been singled out as the lone culpable individual. In a culture of safety, she would still be accountable, but her mistake would be handled in a different, nonpunitive manner. In a culture of safety, this adverse event would be viewed as a learning opportunity, an opportunity to improve the system, adopting a perspective that includes the totality of the patient event. To understand how this adverse event and Belinda’s decision making would be managed in a culture of safety versus a culture of blame, the following section introduces selected cognitive and organizational concepts. Judy, the social worker who met Brad and his mother in the emergency department, is a mandated reporter, which means that she is obligated to report child abuse to Child Protective Services. However, Judy’s overly critical response—without speaking to Belinda and without understanding the complexity of her work situation—is the observer’s unfortunate reaction to an adverse outcome in a culture of blame. It is a reaction that is governed by cognitive phenomena known as hindsight bias and fundamental attribution error (Flick & Schweitzer, 2021). Hindsight bias makes it likely that Judy will simplify the conditions surrounding the mistake, exaggerating what Belinda should have foreseen. At the same time, hindsight bias causes Judy to be unaware of the way her own perception is influenced by knowing the situation’s adverse outcome (Brad’s broken arm). Fundamental attribution error leads Judy to attribute the adverse outcome to Belinda’s personal inadequacies (incompetence and negligence), rather than attributing the negative outcome to situational factors beyond her control (inadequate supervision, an unmanageable caseload, incomplete information, and inadequate training on how to manage suspicions of abuse). Although hindsight bias is always present when a mistake is evaluated in retrospect, and fundamental attribution error is a pervasive tendency, Belinda’s actions would be handled differently in a culture of safety. A culture of safety is also a just culture, which means that Judy, the social worker in the emergency department, would still alert Child Protective Services. However, as an experienced social worker who is fortunate to work in an organization committed to safety, Judy would recognize her unnecessary critical reaction as a knee-jerk human response to an adverse event. She might reflect differently on the impulse to blame a single individual for what is, in fact, a complex situation created within an equally complex system of care. Being more conscious of the totality of factors, ideally, she would contact Belinda to learn more about the situation.
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