Let's look at an example of a situation in which a home health aide confessed that she had been abusing a client.

This could represent a system failure or a discrete failure.

How could it be a system failure?

Perhaps other staff or family members suspected or observed the abuse and failed to report the incident to the agency's administration, or if the agency failed to screen the applicant before hire.

How could it be a discrete failure?

Perhaps the home health aide worked by herself, there were no physical signs of abuse, her victim was not able to communicate, and the agency had no reason to suspect abuse was ocurring.