Ethics Alive! Whoops! Practice Errors and the Ethics of Follow-Up

By: Allan Barsky, JD, MSW, Ph.D.

Editor’s Note: I am pleased to introduce our new ethics columnist, Dr. Allan Barsky, who currently serves as the chair of the National Ethics Committee of the National Association of Social Workers. Listen to a Social Work Podcast interview with him at: http://socialworkpodcast.blogspot.com/2012/12/social-workers-in-court-interview-with.html.

Nobody is perfect. And certainly, it would be naïve to assume that social workers are perfect in their professional practice. Yes, we strive to do the best we can through the processes of self-awareness, deliberate use of self, and critical thinking to integrate theory, knowledge, values, and observations of the people we serve. Proper education, training, supervision, and other risk management strategies can be used to promote the highest standards of practice and reduce the risks of errors. But what happens when we make a mistake—perhaps an error of judgment, an unintentional imposition of biases or assumptions, or providing people with inaccurate information? Our first inclination might be to blame others or hide the error (Wu, 2000). After all, who wants to get into trouble? Perhaps if nobody knows, the trouble will simply go away. Perhaps not. Trying to conceal a mistake may lead to greater client anger, and perhaps more severe professional and legal consequences. This article explores the ethical issues for social workers who have erred in practice and need to determine how to follow up.

To illustrate the importance of follow-up when social workers have erred in practice, consider the following situation.

Chelsey is a child protection worker who was called to investigate a case in which a 13-year-old girl named Gabriele kept running away from her mother, Moira. Moira had been divorced from Gabriele’s father, Fred, for three conflict-ridden years. Moira advised Chelsey that Gabriele was running away because Fred always encouraged her to do so. Chelsey believed Moira’s allegations and initiated proceedings to restrict Gabriele’s access to her father. Gabriele became despondent and started to engage in self-harmful behaviors, including cutting her arms and pulling her hair. Although Chelsey initially viewed Fred as the primary cause of Gabriele’s distress, Chelsey started to realize that Moira may have had borderline personality disorder and falsely accused Fred of causing a rift between Moira and Gabriele. In reality, Gabriele had been trying to extricate herself from an emotionally abusive mother. Chelsey had made matters worse by acting to cut Fred out of Gabriele’s life.

Given this scenario, it seems clear that Chelsey initially made an improper assessment and needs to redress her errors. If she does not take appropriate action, Gabriele and Fred will continue to suffer the consequences. As a professional social worker, Chelsey has a duty to put the interests of the clients first (NASW Code of Ethics, 2008, Standard 1.01; Reamer, 2008). She also has a duty to act with honesty and integrity (Standard 4.04). Despite these ethical duties, Chelsey may be reluctant to admit her mistakes. She may fear the anger or other reactions of her clients. What if they lodge a complaint or initiate legal proceedings against her? She may also fear the response of her supervisor and others at the agency. What if they discipline or fire her? Further, she may fear the reactions of coworkers, friends, and family members who may find out. How can she face the potential embarrassment, not to mention the potential loss of her job and livelihood?

To admit a significant practice error takes moral fortitude. Chelsey needs the strength of moral conviction to come forth and take ownership of her mistakes and commit to correcting them. This does not mean that she needs to become a martyr, surrendering herself for undue punishment and suffering. There are ways to proceed with integrity, but also with support, strategy, and caution. Whenever a social worker thinks she has committed a significant practice error, the worker should consider consulting with the following sources of help:

• Attorney—Attorneys can provide legal consultation and support with the protection of privacy and privilege. This means that the social worker can consult with her own attorney with the assurance that the attorney cannot be called to testify against her. The worker could also consult with the agency’s attorney. However, the worker should understand that this attorney works for the agency, not for the individual worker. Although the agency attorney may provide advice, the worker should know that agency interests and the worker’s personal interests might not coincide (e.g., if the agency decides to lay blame on an individual worker for acting on her own, to protect the agency as a whole from legal liability). Accordingly, consulting one’s own attorney may be preferable. Attorneys can provide advice about the best way to redress errors, for instance, through confidential mediation processes so that conflicts can be resolved without the need for court. An attorney can also advise the worker about self-reporting errors to the NASW and/or to a relevant social work licensing board. The consequences for a self-reported error may be less severe than for an error reported by others, given that the worker has taken responsibility for her actions.

• NASW Office of Ethics and Professional Review (OEPR)—NASW members may call the OEPR for ethics consultation (800-638-8799). The OEPR does not provide case-specific advice or tell members what to do. The OEPR can help members identify relevant ethical standards and risks to manage. It can also identify other resources for support.

• Liability Insurance Company—Workers who have liability insurance may contact their insurance providers for consultation on whether the insurance will cover certain errors. In fact, many insurance policies require that workers report errors to them. The company may offer direction on how to proceed with the case. Insurance may also cover the costs of legal advice and representation. Workers should know that once they report a possible error, their future insurance rates and eligibility for insurance might be affected. They should also know that consequences with the insurance company might be more severe if they do not self-report.

• Clinical supervisor—Clinical supervisors are responsible for the work of their supervisees. Social workers should generally make use of supervision to help them deal with difficult situations, including how to follow up when an error has been made. If a worker has a strong, trusting relationship with the supervisor, it will be easier to discuss such problems and work toward the best resolution possible (Barsky, 2010). Ideally, the supervisor will focus on taking corrective rather than punitive actions. Supervisors should recognize that admitting a mistake is a positive step, and that the practitioner may need the supervisor’s full support in order to deal with the stress and to develop an effective corrective strategy.

When discussing how to deal with a practice error, social workers should address whether and how to disclose the error to the clients (Wu, Cavanaugh, McPhee, Lo, & Micco, 1997). The timing and manner of the disclosure may be crucial to how the client responds (Wu, 2000). Often, a prompt, honest, and open apology—along with a commitment to provide corrective action—will help resolve the issue in an amicable manner. Regardless of the best efforts of a practitioner to apologize and make good, one cannot guarantee a forgiving and friendly response by the client (Berlinger & Wu, 2005). When there is the potential for legal liability, be sure to consult an attorney before making any disclosures to the client.

Some agencies, particularly hospitals and medical facilities, have specific procedures for handling reporting errors. For instance, errors may need to be reported to risk management officers or an agency ethics committee. There may be legal protections for reporting errors, although these should be discussed with an attorney. For instance, social workers acting in a quasi-judicial role may be protected by the legal concept of quasi-judicial immunity. Child protection workers, for instance, are generally protected from civil lawsuits provided that they act in good faith.

In the case situation described above, Chelsey should have been consulting with her agency supervisor and attorney throughout her work with Gabriele’s family. When she realizes her initial assessment was inaccurate, she should go back to her supervisor and agency attorney to provide them with her new information and assessments. Although she may feel embarrassed and anxious about initiating these discussions, her ethical obligations to her clients, her agency, the social work profession, and herself suggest that she should take corrective action.

Chelsey’s supervisor and agency attorney may be able to assist with a plan of action and support. For instance, the supervisor might suggest that a new worker be assigned to work with Gabriele and her family. The new worker would have the advantage of starting fresh, building a positive relationship, making an independent assessment of the family’s situation, and ensuring that everyone is treated fairly.

Chelsey, the supervisor, and attorney should also assess what went awry, in order to ensure that similar errors to do not arise in the future. Does Chelsey need additional training? Does the supervisor need to change her style of supervision or the methods used to assess the nature of risk within families like Gabriele’s? How can the attorney help ensure that workers are relying on good evidence before initiating legal actions that can impinge parental rights? When agencies recognize and review errors, they should look retrospectively and prospectively—what has happened, how can we take corrective steps to redress the error, and what steps can we take to ensure better practice going forward?

When ethical issues arise, do not suffer alone (Gutheil & Brodsky, 2008). Reach out for help.

References

Barsky, A. E. (2010). Ethics and values in social work: An integrative approach to a comprehensive curriculum. New York: Oxford University Press.

Berlinger, N., & Wu, A. (2005). Subtracting insult from injury: Addressing cultural expectations in the disclosure of medical error. Journal of Medical Ethics, 31 (2), 106–108. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1734098/pdf/v031p00106.pdf.

Gutheil, T. G., & Brodsky, A. (2008). Preventing boundary violations in clinical practice. New York: Guilford Press.

National Association of Social Workers (NASW). (2008). NASW Code of Ethics. Washington, DC: NASW.

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

Wu, A. W. (2000). Medical error—The second victim: The doctor who makes the mistake needs help too. British Medical Journal, 18, 726-727. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10720336.

Wu, A. W., Cavanaugh, T. A., McPhee, S. J., Lo, B., & Micco, G. P. (1997). To tell the truth: Ethical and practical issues in disclosing medical mistakes to patients. Journal of General Internal Medicine: Official Journal of the Society for Research and Education in Primary Care Internal Medicine, 12 (12), 770–775. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497204/pdf/jgi_7163.pdf.

Dr. Allan Barsky is Professor of Social Work at Florida Atlantic University and Chair of the National Ethics Committee of the National Association of Social Workers. He is the author of Ethics and Values in Social Work (Oxford University Press), Conflict Resolution for the Helping Professions (Brooks/Cole), and Clinicians in Court (Guilford Press). The views expressed in this article do not necessarily reflect the view of any of the organizations with which Dr. Barsky is affiliated.