• COVID-19
• management
• patient safety
• safety culture
• teamwork

The pursuit of highly reliable performance has been a priority of patient safety policy-makers, practitioners and researchers alike for the past two decades. Aside from narrow examples of sustained reliability (eg, central-line bloodstream infections in the USA1), it has largely been elusive despite considerable effort.2 Prior work has argued that high reliability remains difficult and fragile because our approaches to pursuing it in both practice and research are insufficiently systemic3 or have failed to identify and create behavioural habits of high-reliability organising.4

On this brittle foundation, as it has with so many aspects of life and care delivery, COVID-19 provided a brutal audit.5 A brutal audit commences “at a moment’s notice, everything that was left unprepared becomes a complex problem, and every weakness comes rushing to the forefront” (p. 54).5 Surveys of safety culture during the pandemic makes this weakness evident as data from 54 US hospitals gathered by Press Ganey and 160 hospitals by the Agency for Healthcare Research and Quality provide initial evidence of a significant erosion of safety culture—leadership commitment to safety, prevention and reporting, and communication and collaboration.6 7

Other data find decreases in ratings of patient experience and increases in patient fall and sepsis rates, with the findings more pronounced for hospitals that disallowed patient visitations8 and challenges remain even for hospitals that skilfully deployed technology to support virtual visits.9 We argue that emerging evidence of compromised reliability and safety during COVID-19 reveal the necessity of incorporating a wider set of actors in producing reliability into theory and practice. That is, prior conceptual models of high reliability in healthcare10 emphasised the importance of patients and families as recipients of the processes producing reliability. We argue that patients, families and a broader set of members of …