The Heal Chain

Added on Jun 30, 2015

Before HPI, my High Reliability Organization (HRO) experience was as a Navy fighter pilot, where we applied high reliability principles to efficiently complete kill chains (I know this sounds rough – but that is why we have fighter aircraft and fighter pilots). A kill chain is the sequence of tasks leading to the elimination of a target:

Health system Safety

    SEARCH – search a specified area for possible threat (enemy) aircraft using all available sensors

    DETECT – detect aircraft within the specified area with available sensors

    TRACK – establish accurate position, course, speed, and altitude of the detected aircraft

    IDENTIFY (ID) – determine the correct identity of the aircraft (friendly, neutral, civilian - such as an airliner, or hostile/enemy)

    ENGAGE – employ air-to-air missiles against enemy aircraft while defending against enemy missiles

    ASSESS – evaluate the success of weapon employment, and employ additional weapons, or defend against enemy missiles until the target is eliminated


The Navy’s application of the first kind of high reliability – use systems thinking to get every task right every time. The more reliable we are in each task in the chain – the more likely we are to complete the chain and eliminate the target. System-caused error breaks the chain, resulting in failure to eliminate the target.

Healthcare also uses this first kind of reliability in the Heal Chain. Treatment plans are a series of tasks leading from diagnosis through therapy. The probability of a good outcome depends on the reliability of the chain. If system-caused error breaks the chain, the probability of a good outcome is reduced. Here is an example of system-caused error: the patient shortens the course of antibiotics by choosing not to take the last few doses.

The Navy also has a second kind of reliability. This reliability of the second kind is to prevent those system-caused errors that endanger our people and our mission. This reliability of the second kind is much more subtle than the kill chain. This second kind of reliability is about working diligently together to prevent a very large group of very diverse errors that could result in the loss of aircraft and personnel.

Healthcare also uses the reliability of the second kind to prevent harm – to keep patients safe. First, do no harm is not the same as healing. We need both kinds of reliability. First, do no harm to keep patients safe and the >heal chain to give them the best chance of a good clinical outcome. Here is an example of an error of the second kind: the antibiotic prescribed – and the one the patient takes – has an interaction with their anti-coagulation meds resulting in a hemorrhage.

So here are three questions for us as safety leaders to use this week with our people:

    1. Where in our work do we need reliability of the first kind to complete our heal chain?

    2. Where do we need reliability of the second kind to keep our patients and our people safe?

    3. Where – if anywhere at all – are the two kinds of reliability the same?


Hospital Safety

040920-N-6213R-031 Indian Ocean (Sept. 20, 2004) - Executive Officer of the "Stingers" of Strike Fighter Squadron One One Three (VFA-113), Cmdr. George Slook, launches an AIM-9M Sidewinder air-to-air missile from an F/A-18C Hornet during a missile exercise. The missile tracked and destroyed its target, an air launched LUU-2B/B illumination flare. Missile exercises are held periodically to train pilots in the latest tactics and weapons. USS John C. Stennis (CVN 74) and embarked Carrier Air Wing Fourteen (CVW-14) are currently participating in a scheduled deployment to the Western Pacific Ocean. U.S. Navy photo by Photographer's Mate 3rd Class Mark J. Rebilas (RELEASED)

Hospital Safety regulations