Article Text

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme
  1. Leahora Rotteau1,
  2. Joanne Goldman1,2,3,
  3. Kaveh G. Shojania1,2,4,
  4. Timothy J. Vogus5,
  5. Marlys Christianson6,
  6. G. Ross Baker7,
  7. Paula Rowland3,8,
  8. Maitreya Coffey9,10,11
  1. 1 Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
  2. 2 Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3 Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada
  4. 4 Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  5. 5 Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee, USA
  6. 6 Rotman School of Management, University of Toronto, Toronto, Ontario, Canada
  7. 7 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  8. 8 Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  9. 9 The Hospital for Sick Children, Toronto, Ontario, Canada
  10. 10 Children's Hospitals Solutions for Patient Safety, Cincinnati, Ohio, USA
  11. 11 Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Leahora Rotteau, Centre for Quality Improvment and Patient Safety, University of Toronto, Toronto, ON M4N 3M5, Canada; Leahora.Rotteau{at}


Background Healthcare leaders look to high-reliability organisations (HROs) for strategies to improve safety, despite questions about how to translate these strategies into practice. Weick and Sutcliffe describe five principles exhibited by HROs. Interventions aiming to foster these principles are common in healthcare; however, there have been few examinations of the perceptions of those who have planned or experienced these efforts.

Objective This single-site qualitative study explores how healthcare professionals understand and enact the HRO principles in response to an HRO-inspired hospital-wide safety programme.

Methods We interviewed 71 participants representing hospital executives, programme leadership, and staff and physicians from three clinical services. We observed and collected data from unit and hospital-wide quality and safety meetings and activities. We used thematic analysis to code and analyse the data.

Results Participants reported enactment of the HRO principles ‘preoccupation with failure’, ‘reluctance to simplify interpretations’ and ‘sensitivity to operations’, and described the programme as adding legitimacy, training, and support. However, the programme was more often targeted at, and taken up by, nurses compared with other groups. Participants were less able to identify interventions that supported the HRO principles ‘commitment to resilience’ and ‘deference to expertise’ and reported limited examples of changes in practices related to these principles. Moreover, we identified inconsistent, and even conflicting, understanding of concepts related to the HRO principles, often related to social and professional norms and practices. Finally, an individualised rather than systemic approach hindered collective actions underlying high reliability.

Conclusion Our findings demonstrate that the safety programme supported some HRO principles more than others, and was targeted at, and perceived differently across professional groups leading to inconsistent understanding and enactments of the principles across the organisation. Combining HRO-inspired interventions with more targeted attention to each of the HRO principles could produce greater, more consistent high-reliability practices.

  • Health services research
  • Patient safety
  • Qualitative research
  • Safety culture

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  • The implementation of interventions to instil the five high-reliability organisation (HRO) principles is a common strategy to improve reliability and safety in healthcare organisations, yet there is little empirical research on the perceptions of those who have experienced these programmes.


  • A hospital-wide safety programme that applied a set of HRO-inspired interventions led to variable understanding and enactments of the five HRO principles across the organisation.


  • We provide insights into the design and implementation of HRO-inspired safety programmes in healthcare and call for greater attention to each of the HRO principles to provide a stronger foundation for healthcare organisations to achieve highly reliable practices.


In an effort to improve safety, healthcare leaders frequently look to high-reliability organisations (HROs); organisations that maintain exceptionally safe operations despite hazardous conditions in industries such as nuclear power and aviation.1 2 Weick and Sutcliffe identified five principles characterising HROs: (1) preoccupation with failure, (2) reluctance to simplify interpretations, (3) sensitivity to operations, (4) commitment to resilience and (5) deference to expertise (table 1).3–5 Importation of strategies from other industries into healthcare, however, is a complex endeavour requiring translation and significant adaptation.6

Table 1

Definitions of high-reliability principles

Healthcare safety programmes aiming to enhance reliability have achieved some improvements in outcomes.7–12 However, neither individual healthcare organisations nor the field of healthcare has achieved highly reliable performance.13 14 This may result from limited evidence regarding how organisations become highly reliable, and in particular, how interventions purported to enhance reliability are interpreted across the wide range of healthcare professionals and how these interventions support enactment of the HRO principles.

This paper reports on a qualitative study of a hospital-wide safety programme, ‘Caring Safely’. Caring Safely was implemented in 2015 at a Canadian paediatric referral centre (to be referred to as ‘the hospital’) in conjunction with a large multihospital improvement collaborative.15 The collaborative aims to eliminate preventable harms including serious safety events, hospital-acquired conditions16 17 and employee injuries.7 Caring Safely is the hospital’s name for the programme that comprises a suite of interventions endorsed and taught by the collaborative, including several harm prevention practice bundles and a set of interventions aimed at instilling HRO principles and fostering reliability (see table 2). Further information about Caring Safely implementation is available in online supplemental file 1. This specific set of HRO-inspired interventions has been implemented in approximately 2000 healthcare organisations in North America,18 with many leaders from this collaborative reporting their organisation being at the mature stage of HRO implementation.19 However, the experiences and perceptions of the range of healthcare professionals tasked with enacting the HRO principles in practice have not been systematically explored. This is of particular importance, given that different professional groups have been found to interpret safety culture and performance differently.20 21 Our study aimed to explore how each HRO principle was understood, and perceived to be practised, by healthcare professionals in different clinical contexts, in response to the Caring Safely programme.

Supplemental material

Table 2

Summary of key interventions comprising the Caring Safely programme and associated high-reliability organisation principles


We conducted a single-site qualitative study using interviews, direct observation and document analysis. We focused on hospital leadership, Caring Safely steering committee members (executives, safety leaders and staff, and directors) and three clinical units: medical specialty, intensive care and surgical. The units were purposively selected to reflect diversity in acuity, specialisation and earlier versus later engagement with Caring Safely.

Two authors, LR and JG, conducted 74 semistructured interviews (72 individual interviews, 1 interview with two participants, 1 interview with three participants and 6 follow-up interviews, ranging 26–74 min), with 71 participants with different professional backgrounds and roles (table 3). All Caring Safely steering committee members and hospital executives were invited to participate. We used purposive sampling to recruit participants with varied professional backgrounds and roles (eg, clinical, managerial, quality and safety, medical trainees) from the three units. Interviews were audio recorded and transcribed verbatim. Questions addressed individuals’ understanding and feelings about Caring Safely, experiences implementing the interventions and perceptions of impacts on their behaviours. An interview guide is available as online supplemental file 3. To explore participants’ understanding and experience of the HRO principles, we shared definitions of the principles during the interviews and asked participants to reflect on if, and how, they observed them in practice and whether and under what conditions the Caring Safely interventions enabled their enactment.

Supplemental material

Table 3

Interview participants and observations

LR and JG observed events associated with both Caring Safely and general safety activities (table 3). The observations were ethnographically informed. We were attentive to details such as space, people, objectives, interactions, activities, time, goals and feelings.22 Notes made during each observation were later transcribed. We collected documents including safety coaching encounters, ‘good catch’ reports that document close calls and near misses (ie, situations that could have caused harm, but did not), organisation-wide notifications about safety events and patient safety meeting agendas. Data were collected between April 2017 and February 2019.

We applied a thematic analysis approach to identify patterns across the data.23 LR and JG initially read four interview transcripts and, through discussion, developed a coding guide. The codes were derived directly from the data and using HRO literature as a theoretical framework to help identify how the HRO principles appeared in the data.3 5 24 We were attentive to the explicit language of, and implicit ways of talking about, each principle. Using the coding guide, LR and JG each coded half of the remaining transcripts and observation notes. The research team met regularly to discuss the coding guide and share examples of coded data. We made notes of team discussions and how they influenced analytical insights. The coding guide was iteratively modified to reflect ongoing analysis and team meetings. Analysis and interpretation of data was guided by the constant comparison method as we worked across the data to understand patterns related to each HRO principle and Caring Safely interventions.25


Findings are organised by HRO principle (table 1). For each, we present participants’ understanding of the principle, perceptions of how it was typically enacted (or not) in practice and its perceived relation to Caring Safely interventions. Additional example quotes are available in online supplemental file 2.

Supplemental material

Preoccupation with failure

Caring Safely interventions described as supporting preoccupation with failure include Error Prevention training, sharing safety stories at meetings and serious safety events on the hospital intranet. A ‘good catch’ intervention, which entailed a good catch reporting tool, sending a personal thank you copied to managers and hospital-wide recognition of a small number of good catches, was also described as supporting this principle. These interventions allowed for the identification of errors and contributing factors as well as creating awareness of vulnerabilities, both necessary for preoccupation with failure. Further, the Safety Coach programme supported and recognised staff efforts to identify, and act when faced with, potential failures. Our participants expressed some concerns that the Caring Safely interventions maintained an emphasis on understanding past errors rather than supporting the implementation of changes to prevent future errors.

Participants noted that many of these practices existed prior to Caring Safely, but that formally labelling them as Caring Safely interventions brought attention to the participant’s role in identifying and communicating potential safety issues.

We’re acknowledging the good catches in this culture. I think it’s encouraging people to be more honest…report accurately as opposed to not reporting…[Good catch reporting] gets people’s attention and change happens through that. I think, in general, the culture is better, and I think we’re doing better by our patients by having Caring Safely. (56, Pharmacist)

Participants described challenges maintaining a consistent mindset of wariness, doubt and continuous attention in the face of pressure to be efficient. One pharmacist shared that she often felt pressured to sign off on a prepared medication even when the printed label could not be read properly. The number of safety issues and high-risk practices in the hospital context requires clinicians to make decisions about being preoccupied with failure or moving forward with their responsibilities. One nurse questioned the value of preoccupation with failure as follows:

Preoccupation with failure, is, sometimes you have to say, like, “oh, okay, that one wasn’t a big deal”, because if you focus on every single little mistake, you would be terrified to do anything. (60, Nurse)

Our analysis demonstrated that the Caring Safely interventions were more often targeted at, and taken up by, nurses compared with other groups. While all staff members were required to attend the Error Prevention training, nurses underwent up to several additional hours of training on harm prevention bundles (depending on area and population HAC prevalence) in various formats including annual education days, in-services and self-directed e-learning modules. Despite inviting all staff members, nurses volunteered to take on safety coaching roles at much higher rates than other groups, with nurses comprising more than 80% of the coaches. Nurses more commonly spoke of supportive strategies, such as consistently reinforcing error prevention techniques, encouraging reporting and celebrating good catches, being exhibited by their leaders and safety coaches. Nurses, occupational therapists and pharmacists also described increased comfort proactively discussing safety issues. In contrast, physicians and medical trainees described little or no follow-up after participating in Error Prevention training.

Limited explicit education about HRO principles contributed to varied reactions to the word failure. Participants deliberated about what gets defined as failure in unpredictable environments where non-preventable morbidity and mortality are daily realities. In healthcare, treatment failure is commonly used to reflect limitations of current treatment, not errors in care, potentially adding inconsistency in how failure (as an HRO principle) is perceived.

Something happened, you have not failed. Preoccupation with failure, I think, needs to be reworked. Because the biggest failure is death. Death is something that happens here, morbidity is something that happens. We need to be thinking about reducing it all the time, but we can’t prevent all deaths. (32, Physician)

Reluctance to simplify interpretations

Some participants, mostly nurses, valued the Caring Safely error prevention strategies of ‘taking personal responsibility for safety’ (eg, using the Assertion tool) and ‘maintaining a questioning attitude’ as providing a structured, organisationally supported approach to bringing together different perspectives to increase awareness of problems and potential solutions. Participants did not use the HRO language of reluctance to simplify interpretations, but did emphasise the underlying ideas, such as being open to new information, listening carefully to each other, respecting sceptics and challenging the status quo:

I think the best thing about what Caring Safely did was to affirm the need and the legitimacy of saying, I don’t really understand what you’re saying, or I don’t agree with what you’re saying…I think medicine is still very hierarchical. (60, Nurse)

Another example is the implementation of a harm prevention bundle that required providers to discuss daily whether a patient’s central line can be removed. On the medical specialty unit, this discussion evolved to include concerns about line function and ways to minimise accessing the line. We interpreted this evolution as encouraging the discussion to go beyond the simplified view of whether the central line should stay in or be removed.

Despite Caring Safely strategies to encourage reluctance to simplify interpretations, interprofessional and structural challenges persisted. Some noted limited opportunities to speak during rounds or variable engagement by the range of professionals in clinical discussions due to, for example, healthcare providers being present on the unit at different times.

Finally, similar to reactions to the word failure, some participants reacted to the term simplify in the absence of HRO conceptual understanding. For example, surgeon participants viewed simplification as positive, so reluctance to simplify interpretations was seen as antithetical to their practice.

We are surgeons. We definitely don’t have a reluctance to simplify. We want to simplify as much as possible. Anything that’s complicated we don’t like. We don’t like long stories when we get our patient stories. We like ‘this is the issue, this is how we’re going to fix it, this is how we’re going to move on. (65, Physician)

Sensitivity to operations

Participants highlighted practices associated with sensitivity to operations related to both bringing people together to create a clear picture of the situations they face (eg, Daily Safety Brief (DSB), preoperative huddles) and error prevention techniques that support alertness and attention in clinical practice. Hospital leaders overwhelmingly described sensitivity to operations as relevant to their roles, compared with other principles. They viewed Caring Safely as creating practices that allowed real-time conversations about safety and improved understanding of frontline experiences.

I think as a senior team, we are way more sensitive to operations now. My colleagues in [the executive] office who had zero line of sight on what happens at the frontlines are far more sensitive to the complexity of what happens on the frontlines. (72, Leader)

The DSB was the Caring Safely intervention that leaders associated most with sensitivity to operations. The brief was described as facilitating communication by bringing together leadership of different groups to discuss safety issues.

[The DSB] has given me much more insight, confidence, and understanding of the organization as a whole. I think it also created connections and relationships that enable a better conversation, and [identifies] people to follow-up directly with. (66, Leader)

Despite enthusiasm for the DSB, participants acknowledged limitations. A safety leader noted that those with important insights (eg, managers) were not included. Observations showed the DSB tended to focus on census and access, evidence of shallow sensitivity to operations. Clinical representatives often stated ‘nothing to report and nothing anticipated’, whereas representatives from facility management and security departments reported similar information each day, such as elevator maintenance, fire drills and code calls. A leader described the DSB as “drift[ing] periodically into a bed management meeting” (72, Leader).

Consequently, some participants expressed concern that leaders did not sufficiently recognise the implications of the demands at the point of care.

Sensitivity to operations, I think that maybe needs some work, if I were to be honest. I think there’s still a pretty big disconnect between decision-makers and frontline. (17, Quality Improvement and Patient Safety (QIPS) staff)

Participants described challenges of maintaining organisation-level perspective and awareness of organisational demands and strains, which partly constitutes sensitivity to operations. One manager noted: “our frontline clinicians probably have the least awareness of the big picture” (64, Leader) due to limited opportunities to engage in organisation-level practices. The following quote demonstrates challenges of sensitivity to operations across professional boundaries.

…the pharmacy technicians and the nurses interact quite a bit electronically. I’m not sure that they really understand each other’s day-to-day functions, and what the time pressures for what the other roles are… So, that would be an example of where I feel the frontline isn’t really seeing eye to eye, but there’s nothing really from above to help them see eye to eye. (49, Pharmacist)

The Mindfulness and Resolution tools were described as promoting better in-the-moment understanding by creating space that allows for awareness of one’s actions while counteracting distractions and casualness that impede sensitivity to operations, as noted here:

There is no doubt because when it’s so busy and you’ve got multiple people asking you multiple things at the same time, it’s not humanly possible to manage all that on a consistent basis without risking errors from occurring. Definitely [Mindfulness tool] became a huge Caring Safely behaviour for me. (39, Nurse)

This quote highlights an individual behaviour focus. In contrast, clinicians’ descriptions of other activities not connected to Caring Safely demonstrate collective aspects of sensitivity to operations, such as paying close attention to day-to-day operations and interacting to build a clear picture. One example is the multispecialty preoperative huddle, where individuals introduce themselves and share information. Other examples are nurses’ descriptions of supporting each other with patient care and communicating about high-risk procedures.

[Nurses] pick up on, okay, this [nurse] has been in this room for an hour, I'm going to go check on his other kids because he’s obviously busy right now…maybe there’s four [nurses] helping this one sick kid, then the other nurses will often go and help and check on the other [patients]. (61, Nurse)

Frontline participants noted challenges maintaining awareness and alertness to moment-to-moment changes, as well as negative consequences of activities designed to promote sensitivity to operations, such as the preoperative huddle impacting operating room time. An organisational push for efficiency affected their ability to collectively cultivate a big picture understanding or to stop in the face of an anomaly and reassess, as exemplified by the following observation note describing a discussion about the Mindfulness tool during a Safety Coach meeting:

Someone in the meeting states that frontline nurses do not want to be seen as slowing things down and they do not want to have to ask families to wait. They are uncomfortable and resistant to doing this. The meeting coordinator says that in her experience families are generally understanding if the nurse explains why they have to wait, but then a manager responds that they have had some families who always complain that care is too slow, taking too long, and those interactions can really impact how the nurses react and their willingness to use [Mindfulness tool] in situations where they feel there is time pressure. (Observation 22)

Commitment to resilience

Participants often interpreted commitment to resilience as personal resilience, associated with addressing clinician burnout and providing support following the experience of a safety event.

We’re starting to see more and more the commitment to resilience, and how we support our staff to be resilient in such a complex healthcare environment. There’s been a lot of work on resiliency and joy, and decreasing the amount of burnout in the staff, too, or efforts to do that. (20, QIPS staff)

Clinicians took pride in their ability to problem-solve in the face of unexpected events. However, this emphasised individual management of organisational processes. For example, a pharmacist described an incident where a required medication was not available on a unit, and she drew upon her knowledge to work around current structures and obtain the medication from another unit. Some clinicians viewed individual resilience as central to their clinician identities and attributed it to training and experience.

We would hope that all of us, as surgeons, are trained, because unexpected events happen frequently in our business. (53, Physician)

I wonder how to practice to build capacity to deal with the unexpected. Because in the [critical care unit], we’re just thrown into that. We have to be resilient and to deal with the unexpected, but was there a way to build capacity, I don’t know. Because you just kind of acquire this as you go, like, through experience, and you learn and grow as you go along. (45, Pharmacist)

Caring Safely created comparatively few opportunities for collective training (ie, simulation training) and learning to build a repertoire for resilience. During the data collection period, there was one large-scale simulation of an armed person/hostage situation. Observations of senior-level discussions following the event demonstrated the perceived importance of the simulation, but also the extensive resources it required. Concerns were expressed about the lack of resources for collective professional development, as well as for staffing to create buffers in the system to blunt disruption and provide slack for redeploying resources to respond in ways that systematically address underlying problems.

Deference to expertise

Participants expressed a shared understanding of ‘where the expertise lies’ across the hospital. However, this understanding was most often equated with experience, seniority and professional background as represented through the formal hierarchy rather than an HRO understanding of expertise with the problem at hand.

Many participants described ‘chain of command’ and its correlation to expertise as the guiding logic for dealing with unexpected situations, demonstrating the strong emphasis on hierarchy and clinical specialisation:

I think from a medical standpoint we know who to reach up to and how to find our fellow staff and get them down there. The nurses have all the cellphone numbers of all the other attendings, so we can get that, and the off-service attendings if I need cardiovascular surgery quickly or someone else. (65, Medical Trainee)

Nurses similarly shared numerous examples of reaching out to more experienced nurses or charge nurses when dealing with something unexpected. Given the wide range of roles in the hospital, participants also discussed deference to expertise as knowing who had what expert knowledge based on professional training and role, within and across professional groups:

I think with the interprofessional teams, so [occupational therapists], [physical therapists], dietitians, they’re all very accessible because we have our standard ones that are associated with the units. (19, Nurse)

The above examples demonstrate key properties of expertise in HROs: respect for domain-specific knowledge and experience as well as the ability to obtain expert assistance. However, for physicians, their conception of deference to expertise was challenged given structures of medical education embedded in academic teaching hospitals and the need for consultations with other specialties:

Where we have problems is that because there are parallels, structures of levels of expertise, sometimes you say all right, well, consult this ‘ology’ because they’re more expert, but then you suddenly get somebody with a lower level of expertise. That’s where I think some of the going up the chain of command comes up. [We are] trying to have staff-to-staff communication as opposed to you are an emergency doctor with 10 years of experience, and suddenly, the [first-year resident] in whatever ‘ology’ trumps you. (69, Leader)

Our data demonstrate limited examples of deference to expertise, within or beyond Caring Safely. One participant noted that Caring Safely’s enhanced error investigation process afforded opportunities for inclusive discussions about errors.

When you look at our Serious Safety Events process, before, experts got in a room and said, this is what should have happened…vs now, it’s reviewed by people who are peers and where the expertise actually exists, and you learn a lot more around what is really happening vs what should be happening. (22, QIPS staff)

The following quote demonstrates one example of deference to expertise not directly related to Caring Safely:

My [patient] needed [procedure] and the staff physician said, well, I haven’t done it in a few years, but I can try it. And, I was like, the [respiratory therapist] can try, because they do it every day and they’re available … So, even though, in theory, the staff physician is the top, if you haven’t done a skill in a year, I’ve only got two limbs to work with, I’m not letting you blow a vein … You’re going to the person with the right expertise, not necessarily the person who has the longest years of service. (60, Nurse)

Overall, participants did not express changes to their understanding of expertise or a broader sense of fluid empowerment based on being well suited for a specific problem at hand when discussing the Caring Safely programme.


Our findings provide insights into how the HRO principles are variably understood and enacted in practice in response to Caring Safely, a hospital safety programme based on a widely adopted, HRO-focused suite of interventions. We demonstrate that Caring Safely supported some HRO principles more than others, was targeted at, and perceived differently across professional groups, reinforced individual approaches to reliability and safety, and provided variable attention to structural and social factors that impact adoption.26

Our analysis illustrates how Caring Safely interventions supported preoccupation with failure, reluctance to simplify interpretations and sensitivity to operations through both implementing of new Caring Safely interventions and reinforcing or adding legitimacy to pre-existing practices. Our findings bring attention to how quality and safety interventions interact in practice and contribute to high reliability.14 The range of interventions helped specific groups enact HRO principles in different ways relevant to their role and context, such as nurses with preoccupation with failure (by making failures and threats more discussable) and executives with sensitivity to operations (by enhancing awareness of frontline experience). However, the lack of deliberate and focused attention to each of the principles or investment in education related to behavioural and cognitive underpinnings of high reliability limited habitual and robust uptake of reliability-enhancing practices.27

Although Caring Safely includes interventions intended to instil the HRO principles commitment to resilience and deference to expertise (see table 2), participants did not perceive these principles being addressed by Caring Safely. These principles may be particularly challenging to address given resource constraints and entrenched hierarchies in healthcare,28 29 however, prior research suggests that after-action reviews done with a systems and learning orientation may be a source of resilience.30 There is also evidence that practices of ‘dynamic delegation’ used by trauma teams may build capability for deference to expertise.31 We observed that expertise was regularly conflated with formal authority instead of domain-specific expertise and that error prevention strategies tended to target individual behaviours as opposed to organisational approach to resilience. Though safety efforts must include both individual accountability and system approaches,32 overemphasis on individual action hinders the collective actions foundational to HROs.33 34

We identified inconsistent understanding of the HRO principles among professionals. In some cases, this understanding directly conflicted with how they are enacted in HROs. Some observed deviations from the intended understanding may reflect reasonable modifications in healthcare; however, others may result from a limited attention to the HRO principles and associated concepts in Caring Safely programme design. It may not be necessary for all hospital employees to be deeply familiar with the HRO principles by name, but differing understanding of expertise, failure, resilience, and simplification may unintentionally result in fragmented, hierarchical, and individualised approaches to safety. Furthermore, interventions were targeted at, and taken up by, certain groups, particularly nurses, more than others. These variations may contribute to a piecemeal approach limiting the shared understanding of HRO principles and inhibiting improvements in reliability.1 25 35 Variations also reveal the importance of consistent and comprehensive (ie, cross-profession) leadership support and specific accountability measures.1 36 37

Finally, the focus on efficiency was consistently described as an obstacle to enacting the HRO principles, echoing other examples of safety-efficiency trade-offs.38 We also found variation in how participants perceived safety issues and experienced the principles related to professional norms, clinical experience and training, and care contexts.20 All of which alter or inhibit enacting the HRO principles and reflect the influence of context on implementation efforts.39

Based on our findings, Caring Safely, and other similar programmes, could take three steps to more systematically instil the HRO principles. First, place greater emphasis on teaching the principles to leaders and staff, describing what they mean for everyday work, and pairing them with interventions that place less emphasis on individual training (eg, Error Prevention training) and more on collective problem-solving and scenario-based training to foster mindful interpersonal interactions. Second, provide more sustained coaching on interventions like root cause analysis, DSB and rounding, to turn them into learning-oriented habits that get more members of the care team engaged, and thinking about and acting to enhance safety and reliability (ie, embodying the principles). Third, strive for greater fidelity to the HRO principles by ensuring leaders are not only trained to support intervention implementation, but are provided ongoing feedback (eg, through surveys or audits) on the extent to which the HRO principles are being enacted.

Our findings should be considered in light of this study’s limitations. First, this study was conducted at a single site, potentially limiting direct transferability of our findings. However, given that Caring Safely relies on a widely adopted HRO-inspired set of interventions consistent with current approaches aimed at achieving high reliability in healthcare, our findings can provide insights for organisations engaging in similar work. Second, although data collection occurred over a 2-year period, for interventions aimed at culture change, this is a relatively short timeline. Mindsets and practices have likely continued to evolve in association with Caring Safely.


Our findings demonstrated that Caring Safely heightened enactment of high-reliability practices. However, these enactments were often fragmented and narrow. Therefore, HRO-inspired programmes may benefit from supplementing existing intervention-focused approaches to becoming an HRO with more targeted attention to each of the five HRO principles. Specifically, providing guidance, structure, and support for individuals and groups to engage more fully with the HRO principles and what they mean to each other may enable more consistent, shared understanding of HRO principles and provide a stronger foundation for healthcare organisations to more successfully move along the journey toward high reliability.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by The Hospital for Sick Children Research Ethics Board (#1000054740). Participants gave informed consent to participate in the study before taking part.


Supplementary materials


  • Twitter @JoanneGoldman1

  • Contributors LR, JG, KGS, GRB, PR, MCh, TV and MCo contributed to the study design. JG and LR gained ethics approval, conducted interviews and observations, and led data analysis and interpretation. MCo provided input on the Caring Safely programme details and outcome results. All authors contributed to data interpretation and provided substantial conceptual input. LR drafted the first version of the manuscript with significant input from JG, MCo, TV and KGS. LR, JG, KGS, MCh, TV and MCo contributed to revising the manuscript. All authors read and approved the final manuscript. LR accepts full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding Physician Services Incorporated (grant number 17-09).

  • Competing interests MCo is the Associate Clinical Director of Children’s Hospital Solutions for Patient Safety.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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