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. Normalization of deviance describes the phenomenon of accepting aberrations as a natural course of doing business (Wright et., al, 2020). In alcohol and drug abuse clinics, such as the one in which Belinda and Dr. Bledsoe work, high caseloads are accepted as a fact of life. Despite solid research that proves fatigue leads to a number of problems—lapses in attention, inability to stay focused, reduced motivation, compromised problem solving, confusion, impaired communication, slowed or faulty information processing and judgment, diminished reaction time, and a loss of empathy (Cash et., al, 2020)—probably none of the clinic’s employees would be aware of or question the distraction and fatigue they are experiencing; they would, most likely, accept their stressful work environment as the way things are. Diffusion of responsibility is a term from social psychology that refers to the phenomenon of not performing a task because a person assumes that someone else will take care of it (Liu et al., 2022). In this case, Belinda might assume that the clinic secretary was correct that reporting her concern to Dr. Bledsoe was sufficient or that, after checking with Dr. Bledsoe, the
secretary would handle any necessary reporting requirements. In contrast, in a culture of safety, nothing is assumed. Reporting requirements are clear, and every employee is certain about their responsibility concerning what to report and where it is to be reported. Belinda’s uncertainty about her suspicion of abuse when faced with Dr. Bledsoe’s curt dismissal, and her inability to take corrective action when she believed her client to be at risk, are examples of the authority gradient. The authority gradient—the inability to speak truth to power—reflects power dynamics and the way that differences of opinion are handled in hierarchical cultures (Luva & Naweed, 2022). Workers who perceive themselves to be in lower-status positions with less power are reluctant to give negative information to individuals they perceive to have more authority and are hesitant to question the decisions of their superiors. The authority gradient has been identified as a dynamic that occurs between pilots and copilots, between doctors and nurses, and between students and attending physicians (Murray & Cope, 2021). The authority gradient is disempowered communication, which can have disastrous consequences in hazardous work environments, as members of the field of aviation discovered in the late 1970s. Following several air disasters, the examination of cockpit voice recordings revealed that copilots’ indirect and ineffective wording of critical information failed to capture the pilots’ attention in time to avert disaster. In response, the aviation industry developed a training program to improve situational awareness. Known as crew resource management (CRM), this program emphasized teamwork training and encouraged respectful questioning of authority through the use of assertive communication (Bennett, 2019). Lessons from CRM have been carried to many healthcare organizations as one step on the journey to a safety culture. If the alcohol and drug abuse clinic in which Belinda and Dr. Bledsoe worked were committed to a safety culture and offered such training, Belinda would be comfortable presenting her opinion to Dr. Bledsoe and standing by it. And Dr. Bledsoe, respecting Belinda as a member of the team, would welcome her input. As this case example demonstrates, the way in which human fallibility is managed depends on the cultural context in which it occurs.
ESTABLISHING A CULTURE OF SAFETY
No behavioral healthcare organization has fully achieved a culture of safety, but many are trying. At the forefront of efforts to promote a culture of safety, the Scottish government conducted a large-scale safety assessment survey administered to all frontline staff in every inpatient psychiatric unit in the country. The individuals’ perceptions of safety were assessed using the Mental Health Safety Climate Survey (Cheema et al., 2013). Selected statements include the following: 1. The culture of this ward makes it easy to learn from the mistakes of others. 2. Leaders in my ward listen to me and care about my concerns. 3. Leadership is driving us to be a safety-centered organization. 4. My suggestions about safety would be acted upon if I expressed them to management. 5. I am encouraged by my colleagues to report any safety concerns I may have. 6. I know the proper channels to which I should direct questions regarding patient safety. 7. I would feel safe being treated as a patient in this ward. Strategies to Improve Safety Behavioral health professionals can help their organizations work toward a culture of safety by requesting in-service training for everyone in the organization, from the executive to the clinical staff. At the team level, clinicians can initiate safety briefings, also called safety huddles, which are used in many high-risk industries. Although adverse events and near misses remain
8. Safety briefings are common here. 9. I believe that most adverse events occur as a result of multiple system failures and are not attributable to one individual’s actions. 10. The staff in this ward takes responsibility for patient safety. 11. Patient safety is constantly reinforced as the priority in this ward. Harm to patients was assessed by such measures as unscheduled transfers to acute care; incidents of physical violence, restraint, seclusion, and self-harm; days between deaths on an inpatient unit; and use of emergency detention. The Scottish program was a laudable undertaking, and the researchers investigated the development of measures to assess the percentage of patients who felt safe during admission. Other focal points of their project included determining the frequency of emergency sedation episodes, verbal violence and sexual abuse, including situations where patients received emergency medication without their consent (Cheema et., al 2013). underreported, safety huddles increase safety awareness among frontline staff by regularly engaging staff on the topic of safety and focusing on their daily experience of maintaining client safety. These steps can raise collective awareness, thereby increasing an organization’s capacity to respond correctly in critical moments (Deng et al., 2019). Another strategy for
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