An Honest Reckoning: Reflecting on the Field’s Response to Accusations of Harm and What We Must Do Differently
We make mistakes, we cause harm, and it’s time we own it.
I am not suggesting that all accusations are accurate, nor am I saying that it is fair to conflate events from 30 years ago with the current practices in our field.
I want to challenge our field and every organization involved in behavioral healthcare and treatment. We do not get it right every time; we do not succeed with every case, and at times, we cause harm.
Yes, I said it. Sometimes we cause harm, and unfortunately, we will continue to do so.
Because, to err is human.
Sometimes our outcomes result in harm to the client and/or their family. Is that our intention? Far from it. However, clients do get hurt; they can experience emotional harm from others in treatment, and sadly, at times, our medical care, therapists, and residential staff make mistakes. These can result in harm to the client.
And, we know that research suggests certain types of treatment are ineffective for certain clients. Additionally, at times, the trauma a client experienced prior to treatment can be exacerbated by certain types of treatment.
The people I know who run these programs—many of them—I would trust with my own child. These people are in it for the right reasons and get up each day wanting to make a difference for young people and their families. I do not believe any of the programs I know well or the people who run them intend to do harm, but it is human nature to make mistakes and for things to go awry.
We made a mistake and I was confused as to how to proceed
Years ago, while working at Open Sky, we made a mistake in a client’s care, and I was asked to call and explain it to the family. I needed to break the news and answer any questions they had. I recall being nervous and unsure about how to answer questions while also providing confidence that we would learn from this and prevent it from happening again to their child or others in our care. In the scheme of things, it wasn’t a big deal; the student would be fine, and there weren’t any lasting consequences.
However, I recall being worried about how to walk the fine line and neither overstate our negligence nor minimize the mistake’s impact. So, as any modern person does these days, I did a quick Google search to help me prepare and stumbled upon Leilani Schweitzer’s story about her child’s death and the two distinctly different ways organizations choose to respond to a medical mistake.
Leilani’s tragic story
Leilani lost her son Gabriel while he was in the hospital being treated for a medical condition.
I haven’t lost a child, but I know those who have. There is no greater loss than the loss of a child. The grief is unbearable and lasting.
Like anyone who has lost a loved one, Leilani craved answers. She wanted to know what went wrong. She longed to make sense of Gabriel’s death and this tragedy.
The first hospital where Gabriel was treated chose to defend and deflect. I’m guessing their lawyers advised the hospital administration not to apologize, not to take responsibility, and for her lawyers to talk with their lawyers. They circled the wagons, refused to respond to her inquiries, and didn’t share anything with Leilani. They went silent. Leilani said she felt “humiliated.” She lost her son and now felt humiliated. Humiliated?!
By contrast, the hospital where Gabriel was transferred when he died chose a completely different path. They offered a genuine apology. They were compassionate. They also invited her to be a part of the process as they sought to understand what happened. They maintained routine communication and shared what they knew when they got information. They were transparent and honest. They sought to find answers and get them to her as soon as they were able.
When the hospital conducted its investigation, they learned something unbelievable. A nurse’s actions had inadvertently resulted in his death. Leilani was with her son Gabriel for days and nights while he was in these two hospitals. She was not sleeping well and was tired. The nurse, seeing that Leilani could really use a good night’s sleep, decided to turn off an alarm noise on one of Gabriel’s monitors. That monitor’s alarm was inadvertently disabled, and Gabriel’s distress went undetected, and he died while Leilani slept right beside him.
Devastating. And preventable. It was a genuine effort of care and concern that turned into a tragedy. No bad intention, just a simple, honest mistake. There is nothing the hospital or the nurse can ever do to make up for this. Gabriel is gone forever.
Can you imagine what it felt like for the nurse and the hospital to learn that a simple act of kindness inadvertently resulted in someone’s death? Embarrassing, humiliating, aggravating? I don’t know. But having been on the other end of numerous mistakes my team has made, there are a whole host of feelings I’ve experienced when I’ve learned that we made a mistake in someone’s care— confusion, embarrassment, regret, defensiveness, anger, and worry, to name a few.
There is nothing more devastating I can imagine than unintended harm to those whom we are entrusted to care for.
Mistakes happen, but how we respond can make all the difference.
One hospital’s response to defend and deflect made Leilani feel “humiliated.” I think she said it made her feel like she didn’t exist—like she wasn’t even there. I can only imagine how infuriating this would be.
The other hospital’s response was to be caring and compassionate, to seek the truth and share transparently what they find out. They wanted to find out if there was something they could have done differently. They felt compelled not to have Gabriel’s passing be just another mistake but instead, perhaps, to be a lasting legacy for good.
What the hospital learned is that this was preventable. Instead of shrinking from this and waiting for a lawsuit to reveal the findings, they felt a duty to ensure this never happens again. The monitor should not be able to have the alarm sound shut off to begin with. The technology was susceptible to a simple human decision. So, the hospital was able to work with the manufacturer and get word out to other hospitals to prevent this from happening again.
To Leilani, this has made all the difference. And, it did for that hospital culture, that nurse, and all those involved. They recognized that there are two choices when something goes wrong. You can either learn from it or you can hide from it. One is likely to only make things worse and one can be a path towards reconciliation and resolution.
It is time we learn from our past.
It starts with humility and compassion. It is time we own that to err is human. It is time for us to decide that when someone reports that something went wrong, a mistake might have been made, or an outcome isn’t what they thought it was going to be, we listen and we seek to learn.
We have every right to defend ourselves, to point to the research, to call upon the alumni whose lives have been saved to give testimonials, to point to our accreditation standards or our licensing approvals. But, that is not going to get us out of this situation we are in.
We need to rebuild trust by taking accountability.
I have been intrigued by the idea of trust for a long time. Trust is a pretty nebulous topic. Trust is also fluid. It can come and it can go. We can lose trust and we can regain it. This is the case with all human relationships and so it is true with our clients and their families.. It is time we rebuild trust.
When seeking an understanding of what trust is comprised of, I came across another video by social worker and professor Brené Brown. In it she iintroduces the audience to the anatomy of Trust. The framework is formed by the acronym BRAVING. Any time I think about trust, I repeatedly come back to this. It explains that trust is comprised of seven parts: Boundaries, Reliability, Accountability, Vault (aka confidentiality), Integrity, Non-judgment, and Generosity.
I could dissect nearly every component of this model as a way to determine how to proceed to rebuild trust and yet keep coming back to one singular component: Accountability. Taking accountability for what has happened and what will happen to some of our clients is the place where we own what happened (even if unintended), accept it and rightfully apologize and seek amends. Without accountability, a mistake remains an unattended harm. It will fester and then resentment will build and then trust is lost.
The Opportunity
When we take responsibility and own our mistakes and limitations, we also have a chance to improve, grow, and be better for it. Immediately defending what we do and how we do it is not going to lead to learning and growing and certainly isn’t going to get us trust back.
And, it takes leadership to rebuild trust. Because it takes courage. Like was the case with Gabriel, one hospital can’t make another hospital respond with compassion, transparency, and care. But, we could make it a point in our standards and expectations that we adhere to an accepted standard. I believe that we need to endorse a formal process for mistakes and grievances and equip programs with the skills to handle them.
Evidence proves “doing the right thing is right in every way.”
According to Rick Boothman, University of Michigan’s Health Science’s chief risk officer, “They (facilities) can’t have a trusting patient relationship and then cut and run when a patient gets harmed. More importantly, confronting these issues openly and honestly is critical to building a culture that encourages continual clinical improvement.”
“The bottom line is that doing the right thing is right in every way — for the patients, the providers and the hospital,” according to a study cited by Dr. Evan Benjamin, chief medical officer at Ariadne Labs and a leader in the movement to spread communication and conflict resolution programs. “This analysis clears up any lingering concern about the financial risks of communication and resolution,” Benjamin said. “Transparency, communication, apology and proactive compensation should be the policy of every hospital in the United States.”
Models for Resolution
We don’t have to reinvent the wheel. Proven models and examples exist to support restorative ways to take responsibility for our harmful impacts. The medical world has a process for this, and it is called Communication and Resolution Programs (CRP).
There are different variations of this. There is CANDOR. There is also the Michigan Model. And likely others. We can find the one that suits us or adapt from what already exists.
...I am not saying this is easy, especially when so much of the “harm” is subjective and unlike medical errors that cause physical harm, more difficult to prove. By no means do I want us to open ourselves up to endless complaints and heedless claims. Trust is a two-way street, after all, and not all the people who are claiming to be harmed are trustworthy, but I believe most of them are.
When things go Wrong: A Primer for a Trust-Forward Response
When things go awry, how you respond can make a big difference in the client’s perception of treatment. Informed by the CRP process, here are some lessons I learned for how to respond to breakdowns and mistakes:
Act quickly; the sooner you tell the client and the family that something happened, the better.
Apologize to those harmed. Yes, we are often told not to say we are sorry, but that is inhumane. Saying sorry is just a way of empathizing.
Care for the caregivers: The staff involved were likely doing what they thought they were supposed to do and didn’t intend to do harm. Whether enduring the brunt of an accusation or feeling guilty about making a mistake, these people need to be given support and care, too.
Be transparent: Tell them the facts you have and tell them what you learn as you get the information.
Enroll those harmed (client/family) and involved (staff) in the inquiry process.
Give them a full rundown when the inquiry process is completed.
Consider what appropriate restitution should entail. Sometimes, it is enough to apologize, own it, and share the findings and conclusions from a report. At other times, a payment is justified or reducing or even eliminating fees is warranted.
Stay in communication with those harmed. Some of them will be invested in the positive legacy that can result from the learning, and the subsequent changes can soothe the pain.
Turn Mistakes into a Gift
One thing I have learned in all these years of leadership is that shit happens and how we respond makes all the difference. Mistakes can be devastating or they can be a gift. If we see them for the opportunity they are, we can grow and learn and be stronger for it. It is paramount we take the time to listen to those harmed and to learn about what would reduce the harm and what would prevent things from causing harm in the future. And, so next time your program messes up, I encourage you to own it, take accountability, make amends, learn from it. You and your team will be better for it. So will our entire field.
To hear Leilani’s story, check out her TEDx talk about the importance of transparency and compassion and truth after a medical error: Transparency, Compassion, and Truth in Medical Errors: Leilani Schweitzer at TEDxUniversityofNevada
And, if you and your organization are interested in learning how to incorporate these principles and practices, I’d love to explore how we can help.
