Article Text

Download PDFPDF
Re-examining high reliability: actively organising for safety
  1. Kathleen M Sutcliffe1,2,
  2. Lori Paine2,3,
  3. Peter J Pronovost2,4,5
  1. 1Carey Business School, Johns Hopkins University, Baltimore, Maryland, USA
  2. 2Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA
  3. 3Department of Medical Affairs, Patient Safety, The Johns Hopkins Hospital, Baltimore, Maryland, USA
  4. 4Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
  5. 5Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
  1. Correspondence to Dr Peter J Pronovost, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, 750 E. Pratt Street, 15th floor, Baltimore, MD 21202, USA; ppronovo{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

In the 15 years since To Err is Human was published,1 the US healthcare industry has worked diligently to improve patient safety. Although progress has been made in reducing hospital-acquired conditions2 and, in some cases, rates of surgical mortality,3 healthcare has not achieved broad reductions for most patient harms. In recent years, healthcare has borrowed ideas from industries that have strong safety records, including teamwork and error reporting from aviation, and process improvement techniques from manufacturing. Healthcare's latest patient safety push is to encourage hospitals to become a ‘high reliability organisation’ (HRO).4

HROs have maintained remarkable performance despite complex and risky work. These ultrasafe organisations never set out to be HROs. As Rochlin5 observed: HROs ‘seek an ideal of perfection but never expect to achieve it. They demand complete safety but never expect it. They dread surprise but always anticipate it. They deliver reliability but never take it for granted. They live by the book but are unwilling to die by it’. HROs understand that reliability is an endless journey rather than a simple destination.

Evidence suggests that healthcare is starting to organise for higher reliability. Standardised protocols and checklists,6 preprocedural and postprocedural briefings,7 incident reporting and daily huddles,8 although imperfect,9 ,10 may hold promise for enhancing safer care. These types of activities may be part of an institution's master plan to create a comprehensive operating management system—an organisation-wide integrated approach to manage risk and to achieve safe and reliable performance—similar to the systems found in other industries such as oil and gas. Yet, we think it is more likely that these efforts represent piecemeal and fragmented initiatives adopted to solve particular problems. Regardless, high reliability remains elusive. One explanation is that organisations have failed to widely institutionalise high-reliability habits of …

View Full Text


  • The OMS Framework provides a company-wide, integrated approach to manage risk (including effects, impacts and threats) to achieve benefits and to optimise performance.

  • Contributors All of the authors contributed equally in conceptualising and reporting of the content described in this paper. Relative to the contributors, CGH reviewed and edited the structure and flow of the essay, and VG proofed and edited the essay.

  • Competing interests PJP reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the Gordon and Betty Moore Foundation (research related to patient safety and quality of care), the National Institutes of Health (acute lung injury research) and the American Medical Association Inc. (improve blood pressure control); honoraria from various healthcare organizations for speaking on patient safety and quality (the Leigh Bureau manages these engagements); book royalties from the Penguin Group for his book Safe Patients, Smart Hospitals; and stock and fees to serve as a director for Cantel Medical. PJP is a founder of Patient Doctor Technologies, a start-up company that seeks to enhance the partnership between patients and clinicians with an application called Doctella.

  • Provenance and peer review Not commissioned; externally peer reviewed.