The voices of Urban Institute's researchers and staff
December 2, 2011

Organizational Errors: It Takes A Village To Make Some Kinds of Mistakes

December 2, 2011

Questions keep surfacing at Penn State about who knew what and when. The investigation of charges that a former coach sexually molested young boys on campus is likely to uncover more victims and more instances where administrators turned a blind eye. So far, however, the University itself is mainly escaping any direct blame.

It shouldn’t.

Everyone at Penn State from the janitors to Joe Paterno have argued that they followed the rules and reported what they knew to the appropriate person next up in the chain of command. Yet, nothing was done.

Inaction like this has the makings of what criminologists call “an organizational accident.” Borrowing from medicine, UI consultant James Doyle has developed an organizational accident model positing that  gross miscarriages of justice occur when organizations are set up to ignore those injustices.

To go back to medicine, it wasn’t just the surgeon who cut off your good leg instead of your bad one that made a mistake. The problem was that everyone from the bedside nurse to the operating room staff failed to notice that the wrong leg was being prepped and then amputated.

Death row exonerations tell us a lot about organizational accidents too. Many overturned convictions rest on unreliable evidence: cross-race witness identifications, testimony by jailhouse snitches, and junk science (think bite mark evidence). But zeroing in only on faulty evidence misses a crucial element of wrongful convictions.

Consider this case: an innocent person is convicted based largely on the testimony of a prisoner who heard the defendant “confess.” Even worse than banking on an unreliable witness is using unreliable testimony to implicate the wrong person — often, to the deliberate exclusion of all other possible suspects, including the guilty party. What happens is that prosecutors and investigators building a case around the evidence don’t question it. Then, judges allow the evidence to be admitted and juries believe it. The whole system is so badly warped that it can’t detect errors.

This kind of blindness to error sounds very similar to what we are hearing from not so- Happy Valley these days. And if there was an organizational accident along these lines at Penn State, then the university is culpable.

But it is not enough for universities to stop turning a blind eye to this kind of malfeasance, the solution is for systems to be put in place that detect problems before they become organizational accidents.  For instance, many states now have Capital Defenders’ units that assist defense counsel in death penalty cases. Philadelphia has created a Chief Performance Officer to monitor the behavior of prosecutors.  Universities could establish a similar system of oversight.

Sunshine is the best disinfectant, but it is not enough to simply open the blinds—the sunlight has to be pointed to the dark corners where these appalling acts take place.

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