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sentinel events in health care. Health care is complex and involves the risk of significant and potentially catastrophic consequences when failures occur. HROs operate under these trying conditions and have fewer accidents. They have the ability to provide consistent health care at a high level of excellence over a long period of time. HROs in health care establish and maintain high quality and safety expectations for patient care. Quality and safety error rates are near zero in HROs (Weick & Sutcliffe, 2007).

      The risk of health care error is a function of both probability and consequence. For example, consider the care needed for a dehydrated patient with renal failure. Administering fluids too slowly can result in prolonged hypotension. Administering fluids too rapidly can result in fluid retention and heart failure. An IV pump is used to assist the nurse in providing accurate amounts of fluid. The IV pump decreases the probability of error. However, if the pump is programmed incorrectly or fails completely, the consequences can be catastrophic. By decreasing the probability of an error, HROs operate to make health care systems safer.

      Origins of HRO

      HROs operate in complex, high‐hazard situations for extended periods without serious accidents or catastrophic failures. HROs relentlessly prioritize safety over other performance pressures. An example is a military aircraft carrier. The carrier operates under significant production pressures with aircrafts taking off and landing every 48–60 seconds; constantly changing conditions; and a hierarchical (military) organizational structure. However, personnel consistently prioritize safety and have both the authority and the responsibility to make real‐time operational adjustments to maintain safe operations as the top priority (AHRQ, 2018a, 2018b).

      In the 1970s, research conducted by the National Aeronautics and Space Administration suggested that most commercial airplane crashes were caused by communication failures among pilots and crew, not by mechanical failures. In some cases, co‐pilots were aware that pilots were making unsafe decisions but did not verbalize their concerns because of authority gradient. Authority gradient refers to one's position within a group or profession. It was defined first in aviation when it was noted that pilots and copilots did not always communicate effectively in stressful situations if there was a significant difference in their perceived authority. Multiple aviation, aerospace, and industrial incidents have been attributed to authority gradients. This information was used to develop and implement the Crew Resource Management (CRM) training program. The training program focuses on interpersonal communication, leadership, and decision making in the cockpit, with the informal motto “see it, say it, fix it.” CRM is credited with the dramatic safety improvements in the airline industry (Helmreich, Merritt & Wilhelm, 1999) and has been adapted for use in health care and many other industries.

Similarly, the nuclear power industry has worked for many years to improve safety. The Institute of Nuclear Power Operations defines safety culture characteristics, some that are adaptable to the health care environment, and include: everyone is responsible for safety, leaders demonstrate commitment to safety, trust permeates the organization, decision making reflects safety first, a questioning attitude is cultivated, organizational learning is embraced and safety needs constant examination (Institute of Nuclear Power Operations, 2004). The American College of Healthcare Executives and Institute for Healthcare Improvement (IHI) published a blueprint for safety (2014) and is summarized in Table 4.2. These characteristics are essential for cultural transformation and are as applicable for all health care organizations.

Table 4.2 Safety Culture Characteristics

Establish a vision for safetyBuild trust, respect, and inclusionSelect, develop, and engage your BoardPrioritize safety in the selection and development of leadersLead and reward a just cultureEstablish organization behavior expectations

      Source: Based on American College of Healthcare Executives and Institute for Healthcare Improvement. (2017). Leading a Culture of Safety: A Blueprint for Success. Retrieved from www.osha.gov/shpguidelines/docs/Leading_a_Culture_of_Safety-A_Blueprint_for_Success.pdf

      HRO Characteristics

Weick and Sutcliffe (2007) identified five key principles of HROs that are used to this day, summarized in Table 4.3. These characteristics, when present, help an organization to achieve high reliability. Each characteristic is described in detail below.

Table 4.3 HRO Characteristics

Characteristic	Activities
Preoccupation with failure	Pay attention to near‐miss events Look for weaknesses in the delivery of care
Reluctance to simplify	Acknowledge the complex nature of health care delivery Focus on the root (true) cause of errors
Sensitivity to operations	Develop awareness of how the environment, resources, and supplies impact safety Acknowledge the effect of relationships on safety
Commitment to resilience	Anticipate and alleviate errors Work to decrease risk of harm Develop recovery strategies when adverse events occur
Deference to expertise	Recognize individuals' knowledge, skill, and expertise Employ teamwork Foster active participation by healthcare providers Eliminate hierarchical thinking Share information

      Source: Patti Ludwig‐Beymer.

      Preoccupation with Failure

In preoccupation with failure, nurses and other health care providers are aware that the risk of error is always present. An HRO recognizes that failures can occur and deploys processes to diminish harm. An HRO proactively identifies high risk activities and analyzes all the potential error points in the process. This analysis can be performed as a Failure Modes and Effect Analysis (FMEA), a rigorous process in which a team of clinicians identify and eliminate known and potential failures, errors, or problems before they occur (Hughes, 2008). Failures are prioritized according to the seriousness of the consequences, how frequently they occur, and how easily they can be detected. An FMEA example is provided in Figure 4.2.

FIGURE 4.2 FMEA.

      Source: Patti Ludwig‐Beymer.

      Preoccupation with failure requires that critical information be communicated across time, across the health care team, and across sites of care. For example, a patient may be seen in the Emergency Department (ED) and require admission to the acute care hospital. Prior to transferring the patient, the ED nurse provides a thorough report to the nurse on the receiving unit.

      In preoccupation with failure, nurses report questionable or unsafe practices. They notice and learn from near miss safety events and precursor safety events. These events are viewed as early warnings that something is wrong. Nurses recognize when an error can or has occurred, feel confident in stopping unsafe practices, and assume the responsibility for reporting errors or near misses. The organization then uses the reports to correct unsafe processes through rigorous process improvement activities.

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