A high-reliability organization mindset.

Naseema B Merchant; Jessica O’Neal; Celeste Dealino-Perez; Jenny Xiang; Alfred Montoya; John S Murray

Commentary

A high-reliability organization mindset.

February 22, 2023

Merchant NB, O’Neal J, Dealino-Perez C, et al. Am J Med Qual. 2022;37(6):504-510.

View more articles from the same authors.

The goal for health care organizations to attain high reliability is established but elusive. This article shares insights drawn from a Veterans’ Health system effort to support high reliability. The approach used centered on five components focusing on leadership, data systems, implementation, training, and safety culture.

PubMed citation

Available at

Related Resources From the Same Author(s)

Rate of preventable mortality in hospitalized patients: a systematic review and meta-analysis.

April 1, 2020

The evolving curriculum in quality improvement and patient safety in undergraduate and graduate medical education: a scoping review.

February 15, 2023

Challenges and strategies for patient safety in primary care: a qualitative study.

September 28, 2022

A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes.

November 4, 2020

Maybe they had a bad day: how LGBTQ and BIPOC patients react to bias in healthcare and struggle to speak out.

September 14, 2022

Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room.

July 27, 2022

Patient safety and quality improvement adaptation during the COVID-19 pandemic.

April 21, 2021

How accurately do older adult emergency department patients recall their medications?

August 12, 2020

I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting by trainees.

August 25, 2021

Implementing high-reliability organization principles into practice: a rapid evidence review.

November 11, 2020

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

November 16, 2022

Standardization of pediatric noncardiac operating room to intensive care unit handoffs improves communication and patient care.

October 5, 2022

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

Development of a multicomponent intervention to decrease racial bias among healthcare staff.

July 27, 2022

From HRO to HERO: making health equity a core system capability.

November 24, 2021

ASHP Guidelines on Preventing Diversion of Controlled Substances.

December 14, 2022

Assessing experiences of racism among Black and White patients in the emergency department.

January 25, 2023

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Training in safe opioid prescribing and treatment of opioid use disorder in internal medicine residencies: a national survey of program directors.

October 12, 2022

Medication use evaluation of high-dose long-term opioid de-prescribing in multiple Veterans Affairs medical centers.

January 18, 2023

The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.

February 27, 2019

Communication in health care: impact of language and accent on health care safety, quality, and patient experience.

August 4, 2021

Development and expression of a high-reliability organization.

December 1, 2021

Measuring psychological safety and local learning to enable high reliability organisational change.

November 9, 2022

Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population.

May 19, 2021

Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice.

April 4, 2012

Going to the COVID-19 Gemba: using observation and high reliability strategies to achieve safety in a time of crisis.

June 10, 2020

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme.

June 22, 2022

Learning from safety incidents in high reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare.

March 31, 2021

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

October 20, 2021

Factors associated with potentially harmful medication prescribing in nursing homes: a scoping review.

September 28, 2022

Effectiveness of acute care remote triage systems: a systematic review.

February 5, 2020

Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improvement spread initiative.

October 5, 2022

A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists.

August 7, 2013

Is it time for the mental health field to consider unplanned discharge a key metric of patient safety?

May 4, 2022

Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity.

July 6, 2022

Impact of state nurse practitioner regulations on potentially inappropriate medication prescribing between physicians and nurse practitioners: a national study in the United States.

December 8, 2021

The necessary leadership skillsets for the high-reliability organization framework adoption within acute healthcare organizations.

March 16, 2022

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016

March 3, 2017

The Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey: a brief, diagnostic, and actionable metric for the ability to speak up in healthcare settings.

September 14, 2022

Race differences in reported "near miss" patient safety events in health care system high reliability organizations.

December 15, 2021

High-priority drug-drug interaction clinical decision support overrides in a newly implemented commercial computerized provider order-entry system: override appropriateness and adverse drug events.

May 20, 2020

A machine learning-based clinical decision support system to identify prescriptions with a high risk of medication error.

October 21, 2020

Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients.

December 14, 2005

Do crowdsourced hospital ratings coincide with Hospital Compare measures of clinical and nonclinical quality?

September 12, 2018

A quality improvement initiative to improve patient safety event reporting by residents.

February 9, 2022

Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods.

November 30, 2022

Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review.

November 11, 2020

Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP).

December 3, 2014

Integrating adverse event reporting into a free-text mobile application used in daily workflow increases adverse event reporting by physicians.

January 8, 2020

Indication alerts to improve problem list documentation.

January 26, 2022

Quality and the health system: becoming a high reliability organization.

July 25, 2018

COVID-19 and patient safety: time to tap into our investment in high reliability.

May 12, 2021

Perceptions of nurses who are second victims in a hospital setting.

December 22, 2021

Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities.

March 11, 2020

Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.

January 9, 2019

'I guess I'll wait to hear'- communication of blood test results in primary care a qualitative study.

August 3, 2022

What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization.

October 21, 2020

Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare.

December 20, 2006

Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics.

November 3, 2021

CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event.

April 5, 2023

Severe illness getting noticed sooner - SIGNS-for-Kids: developing an illness recognition tool to connect home and hospital.

January 15, 2020

Healing our own: a randomized trial to assess benefits of peer support.

February 2, 2022

Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review.

December 14, 2022

Effects of healthcare organization actions and policies related to COVID-19 on perceived organizational support among U.S. internists: a national study.

June 1, 2022

Purchase of prescription medicines via social media: a survey-based study of prevalence, risk perceptions, and motivations.

October 27, 2021

Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent recalls.

January 25, 2023

Do falls and other safety issues occur more often during handovers when nurses are away from patients? Findings from a retrospective study design.

November 11, 2020

Understanding patient and clinician reported nonroutine events in ambulatory surgery.

March 22, 2023

Testimonial injustice: linguistic bias in the medical records of black patients and women.

June 6, 2021

Effect of illness severity and comorbidity on patient safety and adverse events.

November 9, 2011

Clinical data sharing improves quality measurement and patient safety.

March 24, 2021

Simulation-based assessment of the management of critical events by board-certified anesthesiologists.

September 13, 2017

Systems science: a primer on high reliability.

October 17, 2018

Better nurse staffing is associated with survival for Black patients and diminishes racial disparities in survival after in-hospital cardiac arrests.

December 9, 2020

Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes.

November 12, 2014

Persisting high rates of omissions during anesthesia induction are decreased by utilization of a pre- & post-induction checklist.

February 1, 2023

Association between limiting the number of open records in a tele-critical care setting and retract-reorder errors.

July 21, 2021

The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.

July 29, 2020

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

Accuracy and safety of medication histories obtained at the time of intensive care unit admission of delirious or mechanically ventilated patients.

April 28, 2021

A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.

July 17, 2013

Mobile physician reporting of clinically significant events—a novel way to improve handoff communication and supervision of resident on call activities.

December 3, 2014

The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment.

July 14, 2021

Society for Maternal-Fetal Medicine Special Statement: telemedicine in obstetrics-quality and safety considerations.

February 1, 2023

Dissemination of Lean methods to improve Pap testing quality and patient safety.

April 8, 2008

Potentially inappropriate medication combination with opioids among older dental patients: a retrospective review of insurance claims data.

October 7, 2020

TRIAD IX: can a patient testimonial safely help ensure prehospital appropriate critical versus end-of-life care?

September 15, 2021

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients.

February 17, 2021

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

Self-reported adherence to high reliability practices among participants in the Children's Hospitals' Solutions for Patient Safety Collaborative.

December 12, 2018

The pharmacist-physician relationship in the detection of ambulatory medication errors.

January 31, 2006

Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.

July 13, 2022

Factors influencing medication errors in the prehospital paramedic environment: a mixed method systematic review.

July 27, 2022

Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety incident.

July 22, 2020

Am I safe here? Improving patients' perceptions of safety in hospitals.

January 25, 2006

The effect of medication reconciliation via a patient portal on medication discrepancies: a randomized noninferiority study.

January 26, 2022

Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology.

November 18, 2020

Competition and health plan performance: evidence from health maintenance organization insurance markets.

April 27, 2005

Human factors analysis of latent safety threats in a pediatric critical care unit.

May 18, 2022

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives.

January 31, 2024

Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration.

December 6, 2023

Implementing patient safety and quality improvement in dermatology.

October 4, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Issues and complexities in safety culture assessment in healthcare.

July 19, 2023

Understanding the root cause analysis process to increase safety event reporting.

July 5, 2023

Systems approach to suicide prevention: strengthening culture, practice, and education.

June 28, 2023

Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada.

June 28, 2023

VHA's movement for change: implementing high-reliability principles and practices.

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Adopting high reliability organization principles to lead a large scale clinical transformation.

April 26, 2023

Tools for establishing a sustainable safety culture within maternity services: a retrospective case study.

April 26, 2023

Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach.

April 19, 2023

The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis.

April 5, 2023

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

Surgeons and systems working together to drive safety and quality.

March 29, 2023

Health technology, quality and safety in a learning health system.

February 15, 2023

Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program.

February 1, 2023

Interventions to increase patient safety in long-term care facilities-umbrella review.

January 25, 2023

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

November 16, 2022

Improving Quality and Safety in Healthcare.

October 26, 2022

An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement.

October 19, 2022

Measure Dx: implementing pathways to discover and learn from diagnostic errors.

September 28, 2022

How to mitigate the effects of cognitive biases during patient safety incident investigations.

September 28, 2022

A health system that won't learn from its mistakes.

September 21, 2022

Experience of learning from everyday work in daily safety huddles: a multi-method study.

September 14, 2022

Patient safety: where to aim when zero harm is not the target-a case for learning and resilience.

August 31, 2022

Positive approaches to safety: learning from what we do well.

August 31, 2022

Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations.

August 17, 2022

See More About The Topic

Quality and Safety Professionals

Latent Errors

Continuous Quality Improvement

Culture of Safety

Learning Organization

A high-reliability organization mindset.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

A high-reliability organization mindset.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site