Eye on Ethics

Saying ‘I’m Sorry’: Social Workers’ Error Management
By Frederic G. Reamer, PhD
January 2014

Some years ago, Rabbi Harold Kushner wrote a poignant book, When Bad Things Happen to Good People. In it, he wisely reflected on our efforts to manage crises and tragedies in our lives.

One sad reality of social work practice is that practitioners sometimes encounter crises when they err and when clients and former clients accuse them of wrongdoing. Too often I’ve consulted on litigation and licensing board cases where unhappy clients and former clients claim, for example, that social workers violated boundaries, mismanaged confidential information, improperly terminated services, provided poor service, or engaged in a conflict of interest. The good news is that it’s relatively rare for social workers to be named in formal complaints. The bad news is that this happens too often.

Although some social workers—a very small minority, fortunately—truly have misbehaved, many formal complaints filed against social workers arise out of honest and unintentional mistakes made by Kushner’s “good people.” Errors happen. Busy and overwhelmed social workers may forget to obtain a client’s consent before releasing sensitive confidential information, neglect to document critically important information in the client’s record, or fail to be available or arrange backup coverage for a client who experiences a crisis.

Mismanaging Error
Unfortunately, research suggests that too often practitioners respond to error in destructive and otherwise unsatisfactory ways (Finkelstein, Wu, Holtzman, & Smith, 1997; Gallagher, Waterman, Ebers, Fraser, & Levinson, 2003; Mazor, Simon, & Gurwitz, 2004). Consider the following:

• Providing incomplete information: Some social workers withhold key information when explaining to a client what went wrong. For example, this would occur when a social worker acknowledges to the client that he shared information with the client’s probation officer about the client’s attendance at treatment meetings but doesn’t tell the client that the social worker inadvertently disclosed confidential information about the client’s HIV-positive status, violating state law and the client’s rights. Another example is when a social worker tells a client that his insurance company refused to authorize additional counseling sessions but doesn’t tell the client that the refusal was due to the social worker’s failure to complete required forms in a timely manner.

• Lying: Occasionally, social workers deliberately give clients incorrect information about an error. An example would be a social worker who lies to her client about having submitted insurance claim forms on time to enable the client to be reimbursed for services. Another example is a social worker who lies about disclosing confidential information to a lawyer representing the client’s estranged spouse, who then used the information against the client during a child custody dispute.

• Avoidance: Sometimes social workers avoid discussing an error. An example would be a social worker who evades a client’s question about whether the social worker overcharged the client for clinical services. Another example would be a social worker who changes the topic of conversation when a client asks the social worker whether he has had social contact with the client’s former spouse, which in fact has occurred.

Managing Error
In recent years, several scholars have explored social work professionals’ management of error (Cantor, 2002; Kraman, 2001; Reamer, 2008; Zimmerman, 2004). Much of the research has focused on the impact of apology when practitioners err and effective ways to minimize harm.

Ideally, social workers would offer clients sincere apologies when warranted in an effort to make amends. This certainly is consistent with social workers’ duty to treat clients with respect. Realistically, however, social workers face significant disincentives to apologize. They may feel a profound sense of shame about their mistakes or fear that any admission of wrongdoing will be used against them in a lawsuit or processing a licensing board complaint.

Social workers have a vested interest in responding to error compassionately and constructively. Although self-protective instincts are understandable, social workers’ principal duty is to protect and care for clients. That said, empirical evidence suggests that professionals who respond to unintentional harm in a forthright, conscientious manner may minimize the likelihood of being sued or having a licensing board complaint filed against them.

For example, in a prominent study conducted at the Lexington VA Medical Center in Kentucky, researchers found that the hospital administration’s earnest attempt to learn about patient injuries, investigate them, and honestly acknowledge errors with patients and next of kin led to very reasonable financial settlements and greatly reduced litigation costs (e.g., attorney fees, expert witness fees). The VA administrators also found that acknowledging error minimized negative publicity (Zimmerman, 2004).

Many health care organizations have established formal error disclosure policies (Mazor et al., 2004). For example, prominent institutions such as the Dana-Farber Cancer Institute in Boston and Johns Hopkins Hospital in Baltimore have made it a policy for their staffers to acknowledge mistakes and apologize. The National Patient Safety Foundation’s statement of principle on the disclosure of health care injuries urges health care professionals to be forthcoming about such injuries and errors and to provide truthful and compassionate explanations to patients and families when errors occur. Some agencies retain consultants to teach staff how to best convey their apologies.

One popular option adopted by several health care organizations is using a so-called care partnership agreement(Liang, 2002). A typical care partnership agreement invites clients to ask questions about their care and notify agency staffers if they observe any mistakes.

Another strategy involves using error investigation teams and error disclosure teams(Liang, 2002). An error investigation team explores the extent to which serious errors occurred and practitioners adhered to policies and appropriate procedures. Typically, the team’s members—usually agency administrators, program managers, and supervisors—have appropriate knowledge and expertise to investigate errors that might have led to adverse events. The team may include on-call members who can be summoned to begin assessment as soon as a potential or actual error is identified.

An error disclosure team assumes responsibility for notifying victims of practitioner error. A client care liaison can communicate with the client or other error victim regarding the progress of any investigation. The client care liaison also offers a point of contact for those seeking information about the error and its investigation. The liaison also can help victims obtain assistance and remedial help to the extent necessary.

Even the most skilled, knowledgeable, and dedicated social workers can make mistakes. Indeed, this is true in every profession and walk of life. What matters is that when errors occur, social workers manage them in a manner consistent with the profession’s deep-seated values and ethical standards.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work at Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, health care, criminal justice, and professional ethics.

References
Cantor, M. D. (2002). Telling patients the truth: A systems approach to disclosing adverse events. Quality and Safety in Health Care, 11(1), 7-8.

Finkelstein, D., Wu, A. W., Holtzman, N. A., & Smith, M. K. (1997). When a physician harms a patient by a medical error: Ethical, legal, and risk-management considerations. Journal of Clinical Ethics, 8(4), 330-335.

Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients’ and physicians’ attitudes regarding the disclosure of medical errors. Journal of the American Medical Association, 289(8), 1001-1007.

Kraman, S. S. (2001). A risk management program based on full disclosure and trust: Does everyone win? Comprehensive Therapy, 27(3), 253-257.

Liang, B. A. (2002). A system of medical error disclosure. Quality and Safety in Health Care, 11(1), 64-68.

Mazor, K. M., Simon, S. R., & Gurwitz, J. H. (2004). Communicating with patients about medical errors: A review of the literature. Archives of Internal Medicine, 164(15), 1690-1697.

Reamer, F. G. (2008). Social workers’ management of error: Ethical and risk management issues. Families in Society, 89(1), 61-68.

Zimmerman, R. (2004). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry.’ Malpractice insurers find owning up to errors soothes patient anger. ‘The risks are extraordinary.’ Journal of the Oklahoma State Medical Association, 97(6), 245-247.