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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. 1Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
  2. 2Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada
  4. 4Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  5. 5Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee, USA
  6. 6Rotman School of Management, University of Toronto, Toronto, Ontario, Canada
  7. 7Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  8. 8Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  9. 9The Hospital for Sick Children, Toronto, Ontario, Canada
  10. 10Children's Hospitals Solutions for Patient Safety, Cincinnati, Ohio, USA
  11. 11Department 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

Data availability statement

No data are available.

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  • 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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