incarceration, as he demonstrated no insight and failed to accept responsibility for his behavior. Just before Charlie’s fifth birthday, Christie phoned Donna and Dan to let them know that adoption was a real possibility. There would be a formal termination hearing, followed by a three- month period to allow the biological parents to appeal the decision if they chose, and then adoption proceedings could be initiated. Christie then cleared her throat and told Donna and Dan that Charlie’s biological father had been raging on Facebook that the “system” stole his babies, and he refused to cease posting despite his therapist’s repeated admonitions. The therapist thought the postings were empty rants, but Christie felt that Donna and Dan should know about them. Donna and Dan found the Facebook postings and had informed the other foster parents at their most recent gathering. They were not excessively concerned, Donna and Dan said; the foster parents of Charlie’s younger sister were frightened and said they would consider moving out of state once the adoption was finalized. The termination hearing was attended by the biological parents, the court-appointed guardian ad litem who represented all three children, two social workers from the different family service agencies working with Charlie’s brother and sister, and Christie. Charlie’s mother sat impassively throughout the hearing and nodded blankly when asked if she understood. Charlie’s father, however, slammed his fist on the table when he heard the decision, cursed Christie and the social workers, and stormed out of the room. Charlie’s father went straight from the courtroom to a bar, where he met a buddy from his anger management class. He had been sure they would be celebrating the return of his children, he said, but he was not worried. One of those “stupid therapists,” he was unsure which, had left a chart open on the table at the hearing, he had been able to write down the addresses of all three children, and he was planning to kidnap them and leave the state. He suggested they leave the bar and drive by each of the houses. His friend declined, saying that he was not feeling well, and left the bar. Worried that possession of this information would jeopardize his own parole, the friend called the therapist who ran the anger management group, who in turn called Christie and the other two social workers. Christie was horrified. Even though she had not been the one who inadvertently displayed the contact information of the three foster families, she immediately informed her supervisor, who reviewed the hospital’s disclosure policy with Christie and encouraged her to meet with Donna and Dan as soon as possible. She encouraged Christie to explain simply and honestly what had happened and offer an apology and ongoing support. She and Christie then role-played a possible scenario. Donna and Dan were surprised but welcoming when Christie asked to come to their home. As soon as they were seated Speaking Up Organizational behavior and culture promote or inhibit workers’ ability to speak up when they observe problems (Weiss & Morrison, 2018). For healthcare professionals, “speaking up” is communicating patient safety concerns and quality of care through information, questions, or opinions where immediate action is needed to avoid patient harm. Researchers found that the organizational climate, particularly a climate of healthcare worker resignation, contributed to a milieu of workplace silence. This silence fed the dynamic of nonreporting of safety concerns and related issues. Speaking up—asserting one’s opinion, questions, or observations about unsafe patient practices—is often difficult for healthcare workers. Unsafe acts that can place a patient in immediate harm complicate this organizational dynamic considerably. Bearing in mind that obstacles to speaking up, many of which have been identified in this course, must be understood so that training and education can address barriers to improvement, researchers (Schwappach & Richard,
around the kitchen table, Christie explained that a mistake had been made. The outpatient clinic’s medical records had all been moved to a secure computer platform a year ago, but both family service agencies still used paper records. One of the other social workers, who was new to the case, had carried a chart to the termination hearing in case information was needed, and she had set the chart on a table where Charlie’s father had seen the foster parents’ addresses. Christie apologized, tearing up slightly, and then outlined suggested steps to protect all three families and also prevent future breaches of confidentiality. She had applied for a restraining order to prevent Charlie’s biological father from contacting the families or coming near their homes or places of work. She had scheduled a meeting with the other social workers in hopes of establishing security precautions. Donna and Dan thanked her and felt comfortable that Christie had done all she could. The next morning Donna called the other two foster mothers. Neither of them had been made aware that Charlie’s biological father knew their addresses. When they called their social workers, they were informed that they were no longer employed at the agencies, and new social workers would be assigned as soon as possible. Case Study 3 Discussion When things go wrong due to some failure in care, as in this case, the failure should be promptly acknowledged, the causes explained as they are understood, and an apology made. In medical settings, it is usually the physician in charge of the case who discloses the mistake. In behavioral health settings, the best person to make the disclosure is the person closest to the patient and their family. Organizational leaders must fully support caregivers as they strive to be more transparent. This case also raises questions about the culture of blame. Termination of the social workers seems like a snap decision. Certainly, an error was made; however, what are the contextual factors that contributed to this error? Was training and communication about transporting records conducted by the agency? Questions of this type, and others, need to be studied and discussed to reduce errors that harm. However, this discussion needs to be systemic in nature to delimit the culture of blame. Full disclosure does not end with truth telling and settling on a plan of remediation. It is an ongoing process of communication and support, with the goal of repairing trust. Patients and families should be offered counseling. If they choose to continue receiving services at the organization where the mistake occurred, professionals should remain in close contact, accompanying the family on their course of recovery as long as necessary (Helmchen et al., 2011). When successful, a full disclosure process repairs trust and allows healing relationships to be maintained, even in the face of tragedy. 2018) identified the following obstacles that perpetuate a culture of silence regarding unsafe patient acts. ● The presence of an audience, namely patients, relatives, or coworkers ● Power hierarchies and related dynamics ● Fears of harming relationships with coworkers and superiors ● Helpless feelings of resignation
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