• Safety culture
• Quality improvement
• Patient safety
• Organizational theory

We are what we repeatedly do. Excellence then, is not an act, but a habit.1

Healthcare leaders,2 ,3 academics4–7 and regulators,8 ,9 continue to push healthcare organisations to emulate high-reliability organisations (HROs) like aircraft carrier flight decks and nuclear power control rooms10 to solve long-standing quality and safety problems in healthcare delivery. The nearly error-free performance of HROs in trying circumstances is a function of mindful organising—a set of behavioural and cognitive processes by which their members discern latent and manifest threats to reliability and act swiftly to resolve them.11 ,12 Emerging evidence suggests that processes of mindful organising are associated with lower error rates,13–15 more reliable service performance16 and even lower turnover.17 Yet despite persistent calls by influential leaders and promising empirical evidence, there is little indication of highly reliable performance in healthcare generally.8 ,9 ,18 In other words, the pursuit of highly reliable healthcare through mindful organising has become a problematic improvement to the problem of medical error.19 We ask, ‘why does high reliability remain so elusive?’

Fostering improvement often starts with looking at what successful people and organisations consistently do as evidenced by the continuing popularity of Steven Covey's 7 Habits of Highly Effective People20 or Charles Duhigg's The Power of Habit.21 Similarly, we argue that the continued unreliability of healthcare delivery results from the failure to turn periodic mindful practice into consistent, enduring habit. In other words, we focus on healthcare organisations that either aspire to be highly reliable and/or have attempted to pursue it in some manner but have not achieved reliable performance. For example, hospital executives may consistently emphasise a zero harm goal and frequently talking with frontline care providers about safety (ie, WalkRounds), yet …