At shift change in the county jail, an incoming shift got their assignments five minutes before they went off duty. The outgoing shift had a long day and the booking officers rushed through briefing, with backpacks on and not much to report. Before booking staff took stock of which inmates were in which holding cells, a call came from control of a local PD with a medically cleared arrestee in the back of the car. The sergeant decided the arrestee would be held away from other arrestees.
Two booking deputies consolidated holding cells to get a cell empty. One arrestee in the holding cell being moved told the deputies he wasn’t moving. The senior deputy advised the arrestee he didn’t have a choice. A voice from the other cell called out, “Yeah, put him in here with me.”
“Hang on.” The sergeant happened to be walking by and saw the train wreck coming. The deputies were about to put two opposing gang members in a cell together and lock the door. The gang members even told the deputies that there was going to be a problem. Disaster averted, but it was a close call!
“You two almost cost us a trip to the hospital,” said the sergeant.
Dodging a bullet
Preventable moments like a close call between two gang members happen all the time in corrections facilities. When, however, mistakes and bad decisions don’t end in bad results, we normally do not write incident reports. In some cases, a supervisor will write up the staff member who almost caused a disaster, but without any exploration into what could be institutionally changed to avoid the same mistake.
How many times have you written an incident report, shaking your head and counting your lucky stars that a series of missteps did not lead to one of your partners getting hurt, or an outcome in your facility that would end up in the news? How many times have you breathed a sigh of relief after seeing your career flash before your eyes because something pretty bad almost happened?
In the corrections world, new policies, improved best practices and case law are generally changed after bad outcomes. When someone gets hurt, an agency is sued, or an inmate escapes, the response is often swift and the changes dramatic. Corrections staff are terminated, and policies picked apart.
When a bad set of circumstances does not create a bad outcome, however, we laugh in relief and shake our head. Maybe we give the officer who almost lost their job some tough love and let them know, “You just dodged a bullet.”
What we generally do not do is tell anyone in authority about the incident. We don’t want to get a partner in trouble for a mistake that didn’t cause any issues, right? So, what happens the next time one of your partners makes the same mistake and something bad does happen? Could an institution avoid that injury, that lawsuit, or that riot with some risk management? Would your agency save money with a reporting system in place that allows staff to report a close call without getting in trouble?
Near misses and close calls
In 1976, NASA established the aviation safety reporting system (ASRS) with the mission of improving safety. The program serves commercial aviation, as well as government agencies involved in flying. This reporting system encourages pilots, air traffic controllers and others involved in the aviation world to submit reports when they see something that could potentially lead to a bad outcome. Two of the key components of the program’s success are anonymity and limited immunity.
The program processed over 1.6 million reports by 2019 and produced over 60 safety studies.
In the manufacturing sector, risk management departments pay attention to near misses and close calls. There is a cultural expectation, which is spurred on by the certifications of factories, that when a mistake is made, the employees involved in the mistake will self-report to their factory floor managers. There is also an expectation that when a mistake is made, management will not punish an employee who self-reports an honest mistake or judgment call that could have ended badly.
You are the risk manager
In the facility from the scenario above, the outgoing shift should have provided a better briefing and the incoming shift should have paid closer attention to what the two gang members were trying to say. But there were other lessons to be learned. The institutional issue, in this case, is that briefings have not been prioritized. The shift supervisor didn’t think ahead to assign positions in advance, knowing they could be late from a meeting. The facility commander didn’t schedule any overlap between shifts, forcing staff members to work for free by receiving briefing off the clock. A deeper look would find that there are no visual safeguards to help staff avoid mixing opposing gang members in one holding cell. How do we get to pick apart our procedures to make improvements before a bad outcome?
Starting with self-reflection always gives you credibility if you are going to discuss what went wrong in an incident. Any piece of an incident that has gone wrong is attached to someone’s action or inaction, whether related to bad policy that no one is willing to change, or good policy that staff members fail to follow properly. Finding out what you could have done better is a good start. Then look for anything else that could have gone better.
Telling someone else what you think they did wrong can be a little dicey. You have to do it without attacking character and sticking to a mechanical critique of what went wrong. As the receiver of constructive criticism, you will get more honesty if you invite and appreciate the criticism, knowing you will improve based on the useful information. Constructive criticism is a powerful communication tool for a team, but it takes a lot of trust between team members to give and receive criticism. On the giving side, trusting that the receiver won’t blow up and shut down when hearing criticism. On the receiving side, knowing that your teammate is on your side when s/he gives you criticism.
Once you find out what you can personally improve to avoid a tragedy down the road, start looking for how a policy or procedure can help. Holding cells can come with a system of signs for booking staff that alert all staff members of high-risk arrestees and their locations in real-time. A good risk manager may find that the money saved by not overlapping shifts for a good briefing may not be worth the one lawsuit an agency can avoid with better communications between shifts.
When you come up with as much information as you can and find possible solutions to avoid a bad result in the future, put together a report to send up the chain of command. A good commander will be thrilled to have the information if it is presented with integrity.
Improving policies, best practices and procedures before disaster strikes in your correctional facility will save you and your team a lot of grief down the road. Reporting and dissecting close calls is an investment that will improve correctional officer safety while decreasing correctional facility liability. Having an effective safety reporting system in place will save the controlling agency the most liability by illustrating that decision-makers are actively seeking improvements in safety before critical incidents have a chance to cause any damage.
