You Can’t Fix A Secret

You Can’t Fix A Secret

There is a particular kind of organisational silence that looks, from the outside, like stability. No complaints. No incident reports. No difficult conversations. Everything, apparently, fine.

It isn’t fine. It’s just hidden.

The most dangerous problems in organisations are not the ones people are talking about. They are the ones people have learned it isn’t safe to raise. And the gap between what people know and what they feel able to say is where harm quietly accumulates — in healthcare, in aviation, in manufacturing, in every domain where people work together under pressure and the stakes are real.

“Underneath every simple, obvious story about ‘human error,’ there is a deeper, more complex story about the organisation.” — Sidney Dekker

When something goes wrong, the instinct is often to find the person responsible and hold them accountable. This feels just. It feels like doing something. But blame (however emotionally satisfying) rarely changes the conditions that made the error possible. The next person walks into the same system, faces the same pressures, and the same thing happens again.

“Blame is emotionally important, not operationally important.” — Todd Conklin

What blame does reliably produce is silence. If people learn that honesty about error leads to punishment, they stop being honest about error. Incident reports go unfiled. Near-misses go undiscussed. Reflective notes become performative. The data that organisations need to improve dries up — not because nothing is going wrong, but because people have made a rational calculation that speaking up costs more than staying quiet.

This is the deepest problem with cultures that punish error: they don’t reduce mistakes. They just make mistakes invisible. And invisible mistakes compound. They accumulate in the system, layer on layer, until the conditions are loaded enough that something catastrophic follows from what looks, to an outside observer, like a trivial cause.

“A bad system will beat a good person every time.” — W. E. Deming

The cases of Dr Hadiza Bawa-Garba and RaDonda Vaught illustrate this with particular clarity. Both made errors in systems that were under-resourced and poorly designed. Both did what we say we want people to do: they were honest about it. One had her reflective learning notes obtained by the prosecution. The other disclosed her error immediately, while the institution that concealed its systemic role faced no criminal proceedings. The message sent to entire professions was unambiguous: honesty about error carries risk. Over 80% of junior doctors changed how they write reflective notes after Bawa-Garba. That is not cowardice. That is a rational response to observed evidence about what happens when you tell the truth.

“Being blamed in the context of a safety investigation is contrary to the purpose of a safety investigation, partly because it is deathly for an occurrence reporting system, and for any subsequent investigations and learning.” — Steven Shorrock

We cannot learn from things we don’t know about. We cannot fix what has been kept secret. And we cannot create the conditions for honesty by punishing honesty — however understandable that impulse is, and however much it might feel like accountability.

Real accountability (the kind that actually improves systems and prevents future harm) requires people to feel safe enough to say what happened, what they knew, what they were working around, and what they’d been told to ignore. It requires organisations to treat that honesty as a gift rather than a liability.

“Every system is perfectly designed to get the results it gets.” — Donella Meadows

If the result we are getting is silence, we should ask what the system is rewarding. If people are hiding mistakes, covering near-misses, and writing carefully sanitised reflections designed to protect themselves rather than illuminate what happened — that is not a people problem. It is a system that has taught people, through experience, that the truth is dangerous.

You can’t fix a secret. But you can build the conditions in which secrets don’t need to be kept. That is what psychological safety is for.