Improving practice: Child protection as a systems problem

This paper argues for treating the task of improving the child protection services as a systems problem and for adopting the system-focused approach to investigating errors that has been developed in areas of medicine and engineering where safety is a high priority. It outlines how this approach differs from the traditional way of examining errors and how it leads to different types of solutions. Traditional inquiries tend to stop once human error has been found, whereas a systems approach treats human error as the starting point and examines the whole context in which the operator was working to see how this impacted on their ability to perform well. The article outlines some factors that seem particularly problematic and worthy of closer analysis in current child protection services. A better understanding of the factors that are adversely effecting practitioners' level of performance offers the potential for identifying more effective solutions. These typically take the form of modifying the tasks so that they make more realistic and feasible demands on human cognitive and emotional abilities.