Examining decision errors in child protection: A new application of root cause analysis

Case decision making in child protective services typically occurs in stressful, complex environments fraught with uncertainties. Mistakes in judgment and decision making are inevitable under such difficult circumstances. Casework errors resulting from unrecognized risks sometimes lead to the serious injury or untimely death of a child whose caregivers have been the subject of investigation. While it is easy to blame individual caseworkers for poor decision making, it is increasingly recognized that errors are likely to result as much from problems with organizational processes, as individual misjudgments. This paper describes a project whose goals are to uncover decision errors in child protection investigations and trace their origins in cases where children have died during or after an investigation. Root cause analysis, the method chosen for examining project cases, was originally designed to reveal multi-level factors contributing to negative outcomes in other high risk enterprises, such as chemical factory explosions, airline crashes, and failed military operations. To our knowledge, it has not been applied to the study of decision making in human services. An illustration of its use with a case example serves as a springboard for a discussion of the particular approach to analysis we chose, application issues, and implications for practice. (c) 2004 Elsevier Ltd. All rights reserved.