This commentary reviews the characteristics of a high-reliability organization (HRO). The authors present the story of a pediatric intensive care unit at a tertiary children’s hospital to illustrate how HRO processes were adopted. They discuss how the unit evolved into a functioning and safe HRO and how staff reverted to a standard medical model when advocates of the HRO model left the organization. The authors emphasize the importance of constant attention to factors that support an HRO.