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A case of the birth and death of a high reliability healthcare organisation
  1. K H Roberts1,
  2. P Madsen1,
  3. V Desai1,
  4. D Van Stralen2
  1. 1Walter A Haas School of Business, University of California, Berkeley, CA, USA
  2. 2Loma Linda University Medical School, Loma Linda, CA, USA
  1. Correspondence to:
 Dr K H Roberts
 Walter A Haas School of Business, 545 Student Services Building, University of California, Berkeley, CA 94720, USA;


High reliability organisations (HROs) are those in which errors rarely occur. To accomplish this they conduct relatively error free operations over long periods of time and make consistently good decisions resulting in high quality and reliability. Some organisational processes that characterise HROs are process auditing, implementing appropriate reward systems, avoiding quality degradation, appropriately perceiving that risk exists and developing strategies to deal with it, and command and control. Command and control processes include migrating decision making, redundancy in people or hardware, developing situational awareness, formal rules and procedures, and training. These processes must be tailored to the specific organisation implementing them. These processes were applied to a paediatric intensive care unit (PICU) where care was derived from problem solving methodology rather than protocol. After a leadership change, the unit returned to the hierarchical medical model of care. Important outcome variables such as infant mortality, patient return to the PICU after discharge, days on the PICU, air transports, degraded. Implications for clinical practice include providing caregivers with sufficient flexibility to meet changing situations, encouraging teamwork, and avoiding shaming, naming, and blaming.

  • HRO, high reliability organisation
  • PICU, paediatric intensive care unit
  • RCP, respiratory care practitioner
  • high reliability organisations
  • paediatric intensive care units
  • quality improvement
  • patient safety

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  • This work was partially supported by National Science Foundation Grant SES-0105402.