Re-examining high reliability: actively organising for safety

In the 15 years since To Err is Human was published,1 the US healthcare industry has worked diligently to improve patient safety. Although progress has been made in reducing hospital-acquired conditions2 and, in some cases, rates of surgical mortality,3 healthcare has not achieved broad reductions for most patient harms. In recent years, healthcare has borrowed ideas from industries that have strong safety records, including teamwork and error reporting from aviation, and process improvement techniques from manufacturing. Healthcare's latest patient safety push is to encourage hospitals to become a ‘high reliability organisation’ (HRO).4 HROs have maintained remarkable performance despite complex and risky work. These ultrasafe organisations never set out to be HROs. As Rochlin5 observed: HROs ‘seek an ideal of perfection but never expect to achieve it. They demand complete safety but never expect it. They dread surprise but always anticipate it. They deliver reliability but never take it for granted. They live by the book but are unwilling to die by it’. HROs understand that reliability is an endless journey rather than a simple destination. Evidence suggests that healthcare is starting to organise for higher reliability. Standardised protocols and checklists,6 preprocedural and postprocedural briefings,7 incident reporting and daily huddles,8 although imperfect,9 ,10 may hold promise for enhancing safer care. These types of activities may be part of an institution's master plan to create a comprehensive operating management system—an organisation-wide integrated approach to manage risk and to achieve safe and reliable performance—similar to the systems found in other industries such as oil and gas. Yet, we think it is more likely that these efforts represent piecemeal and fragmented initiatives adopted to solve particular problems. Regardless, high reliability remains elusive. One explanation is that organisations have failed to widely institutionalise high-reliability habits of …