Elevating Safety: Taking a Page from the High Reliability Playbook

Added on May 19, 2016

Elevating Safety: Taking a Page from the High Reliability Playbook
By Diana Mahoney
From Industry Edge May 2016

More than 250,000 Americans die each year from medical errors, accounting for approximately 9.5% of all deaths annually in the United States. This finding, reported this month in The BMJ by researchers from Johns Hopkins Medicine, shines a harsh light on what the study investigators call “medical care gone awry as a cause of death.” It also signals an urgent call to health care leaders to elevate patient safety to the top of their list of strategic priorities.

Patient safety became a hot-button topic in the health care industry in 1999, when the Institute of Medicine issued its landmark report, ​. The report identified profound defects in care delivery that contributed to as many as 98,000 deaths annually, based on the authors’ estimates. Since then, other researchers, including the authors of the BMJ report, have suggested that the number of deaths attributable to medical errors might be as high as 400,000 annually.

“Despite widespread efforts to improve the quality of health care, many patients still suffer preventable harm every day,” said Dr. James Merlino, president and chief medical officer of Strategic Consulting at Press Ganey. “The truth is, we can talk about improving the quality of the care we deliver, but there is no quality if the care isn’t safe.”

Most medical errors occur because systems are not in place to prevent them, not because of a failure by an individual doctor or nurse. When health care practices and processes are not consistently reliable, patients and the providers caring for them are vulnerable. As such, hospitals and health systems must adopt comprehensive strategies for detecting, correcting and preventing system weaknesses that could lead to harm. Most importantly, they must develop and nurture a positive safety culture that recognizes the inevitability of error and seeks to identify and prevent the underlying causes.

“There has been a lot of focus on improvement processes and technology in health care, and those are all well and good, but culture is the top system contributor to safety,” Steve Kreiser, Press Ganey Strategic Consulting director, said in a presentation at the 2016 Press Ganey Regional Educational Symposium in San Diego.

A true safety culture is one in which leadership is visibly committed to safety improvement and staff are encouraged and expected to openly share safety information and report adverse events and unsafe conditions, Kreiser said. When the question around every serious safety event becomes “What went wrong?” rather than “Who is at fault?” the organization can establish processes and protocols to shore up the infrastructure to prevent the same mistake from happening again.

A former U.S. Navy fighter pilot, Kreiser draws parallels between health care, naval aviation and other high-risk industries. “In a high-risk environment like aviation or health care, you have to be right every time. One mistake or system breakdown can have tragic consequences,” he said.

When failure is not an option, organizations focus their energies on developing highly reliable processes, policies, technologies and mindsets to prevent it. “High Reliability Organizations make safety a precondition of organizational design,” said Kreiser.

Realistically, “being right every time” is an impossible outcome, but it’s a necessary objective, and it’s one that has been successfully adopted in other industries. In naval aviation, for example, between 1954 and 2014, the mishap rate per 100,000 flight hours dropped from 54 to less than two, Kreiser said. The dramatic improvement came as a result of fundamental structural, organizational and educational changes and meticulous attention to human factors designed to reduce the probability that errors would occur.

The changes reflect the core principles of High Reliability Organizations described by Karl Weick and Kathleen Sutcliffe,1 which are fully transferable across high-risk operations, including health care, Kreiser said. These include

  • Preoccupation with Failure: operating with a chronic awareness of the possibility of unexpected events that may jeopardize safety, and engaging in proactive and preemptive analysis and discussion
  • Sensitivity to Operations: paying attention to what’s happening on the front line, and participating in ongoing dialogue about the human and organizational factors that determine the safety of a system as a whole
  • Reluctance to Simplify Interpretations: taking deliberate steps to question assumptions and collect information to create a more complete and nuanced picture of operations
  • Commitment to Resilience: developing capabilities to detect, contain and recover from errors that have already occurred before they get worse and cause additional harm
  • Deference to Expertise: yielding decision-making authority to the person or people who have the most expertise with the problem at hand, regardless of organizational position

In health care, as in other industries, developing systems to prevent errors requires knowing where errors are likely to occur. To this end, organizations must promote an environment in which event/problem reporting is welcomed and encouraged and “near misses” are explored with as much scrutiny as sentinel events. “Even small, inconsequential errors are a symptom that something is wrong,” Kreiser said. In the immediate short term, a “healthy” reporting culture will lead to an apparent increase in safety events, not because more events are occurring, but because the actual events and near misses are more visible.

For safety-focused cultural transformation and improvement efforts to take root, leaders must demonstrate a commitment to High Reliability, and everyone within the organization must own the safety mission. The steps toward achieving this may vary by organization, but the net result is the same: the creation of a safety culture with measurable improvements in safety outcomes.


1 Weick, Karl E., and Kathleen M. Sutcliffe. 2001. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass.