Achieving Zero Harm with High Reliability Organizations

Amanda Bonser

In Brief

6-Minute Read

For decades, the pervasiveness of medical errors has stirred concern and controversy inside and outside the healthcare industry. Most are familiar with statistics labeling medical errors as a leading cause of death in the U.S.

Medical errors happen far too often in an industry predicated on “zero harm.” That is why healthcare professionals and healthcare organizations are focusing more on the journey to high reliability. However, the pursuit of high reliability does not happen overnight. The journey is ongoing, and organizations must begin now in order to thrive in the future of healthcare.

Defining the High Reliability Organization

The term “high reliability” describes an organizational culture that strives to achieve error-free performance and safety in every procedure, every time — all while operating in complex, high-risk or hazardous environments. A high reliability organization (HRO) is an organization with predictable and repeatable systems that support consistent operations while catching and correcting potentially catastrophic errors before they happen.

In healthcare, HROs have come to represent improvements in patient safety through the elimination of unwarranted variation in care delivery — while also improving clinical results and reducing costs. Reaching this level of clinical and operational excellence frequently requires a transformation of culture — fundamentally changing the attitudes, beliefs, goals and values of an organization.

Other high-risk industries, such as the military, commercial aviation, nuclear power and oil/gas, have adopted high reliability strategies. Similar to the healthcare industry, these industries function in high-risk, high-stress conditions; work under time pressures; utilize advanced technologies; face complex regulatory pressures; and operate at high capacity during peak demand. However, when comparing error rates, other industries surpass the quality and safety levels of hospitals, ambulatory centers, pharmacies and other healthcare delivery systems.

The Characteristics of a High Reliability Organization

High reliability organizations display consistent characteristics. One common thread across these characteristics is a constant state of awareness to recognize errors quickly and intervene before they become catastrophic and impact safety.

The characteristics shared across high reliability organizations include:

Sensitivity to Operations

High reliability organizations are mindful of day-to-day operations and give team members the necessary resources and abilities to handle changing situations. One important organizational mindset is the recognition that healthcare is a complex, dynamic environment. Those at the executive level can’t react as quickly as caregivers who work directly with patients. Decision making is decentralized, empowering team members to find hidden threats, resolve them and report any incidents or near misses.

Standardized, regular check-ins with employees and patients increase operational awareness at the top of the organization regarding issues that may be present, and every process prioritizes accountability.

Reluctance to Simplify

High reliability organizations work to simplify procedures when necessary to improve patient safety, and the simplest diagnosis is often considered by the team when examining a patient. HROs are reluctant to simplify explanations or interpretations of problems and their causes. The root causes of a complex situation may be difficult to easily determine, so team members look beyond simple explanations for the cause of the safety issue. Due to their reluctance to simplify, teams also invest the time to understand how a proposed solution will impact other areas of care delivery and operations.

In high reliability organizations, teams understand that a new error type or source can arise at any time. Determining a solution doesn’t mean that they have anticipated every possibility for error or system failure, so they remain diligent.

Preoccupation with Failure

HRO teams acknowledge the high-risk, error-prone nature of healthcare organizations. Keeping track of successes isn’t as important as learning from errors and making necessary adjustments to prevent them. Teams are constantly aware of what might go wrong and know they must be prepared for an error to occur unexpectedly at any time. The organization practices simulations of unexpected situations and is never complacent with a long, dependable safety record.

Team members follow up immediately if they feel something might be wrong and consistently use practiced processes and behavioral skills, such as situational awareness and assertive communication, to resolve issues. They constantly question their ideas and assumptions about safety and adapt them as required for continuous improvement. An HRO considers a near miss as evidence that a system or human failure is present and regards it as an opportunity to improve the process. Even a small deviation from established procedure is unacceptable for fear that it might become normalized over time.

Deference to Expertise

In an HRO, team members defer to individuals with the most knowledge or experience relevant to a critical situation — regardless of title or rank. Senior managers may see the big picture of patient safety goals but may not know important details about safety challenges that individual caregivers face. Employees with the most expertise are likely to have a better perception of where errors can occur and what system changes should be made to prevent them.

In cases where the traditional chain of command is de-emphasized in favor of expertise, the HRO avoids settling for a decision from the member who has the most authority but not the most relevant information. Deference to expertise also allows members to question and remind others about safety practices, such as washing hands or properly completing a patient chart, without regard to anyone’s position in the hierarchy.

Commitment to Resilience

When unexpected events occur, high reliability organizations continue functioning. A commitment to resilience helps team members improvise and quickly develop plans to respond to unanticipated situations. First, they resolve each problem. Then they regroup and learn from the experience, taking notice of individual and team performance and searching for ways to improve.

Stress levels usually increase and mental acuity reduces to tunnel vision when unexpected events occur; this prevents individual team members from seeing important and obvious cues about the situation. In an ideal state of high reliability, members are trained to manage high levels of stress and maintain situational awareness to keep focused on the big picture.

It takes years to develop a deep-rooted organizational culture of mindfulness or alertness to safety. Healthcare organizations pursuing zero harm must create a culture where vigilance and constant improvement is everyone’s responsibility.


No matter where organizations are on their journey to zero harm, organizations should:
  • Think differently.
    Don’t settle for the average; begin shaping operations and culture around a journey to zero harm.
  • Plan differently.
    Design processes that are predictable and repeatable, and provide teams with training to develop the specific behavioral skills needed to operate as an HRO.
  • Act differently.
    Focus at every level on reducing variation and creating predictability and process consistency.

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