In High-Reliability Organizations (HROs), errors are recognized early to prevent them from escalating into serious incidents that threaten patient safety. HROs promote transparency and teamwork while effectively leveraging digital technologies. It’s a culture where leaders are both supportive and demanding.
Humans make mistakes. But it’s not the biggest problem
Medical errors can stem from knowledge gaps, fatigue, stress, or biases. They often remain undetected, mainly when decisions are made individually, may be overlooked or ignored, and “swept under the carpet.” How a healthcare facility manages medical mistakes depends on the organizational culture – its values, beliefs, attitudes, and leadership.
The statistics are alarming: One in ten patients is harmed during their hospital stay, and diagnostic errors are estimated at around 11%. Even if most of them are preventable, they repeatedly occur because diagnosis is still too often based on intuition instead of data, treatment plans follow outdated protocols, and medical workers make decisions trusting their experience instead of cooperating in teams.
HROs try to change this by fostering a culture that encourages transparency and psychological safety while applying technologies that are trusted and used correctly.
HROs dare to face the problem
The concept of high-reliability organizations was initially developed in industries like nuclear power and commercial aviation, where even minor errors can have catastrophic consequences. Mistakes must be spotted as early as possible – there is no place for ego-driven decision-making or communication blind spots. What matters most is a readiness to embrace mistakes, empathy, cooperation among teams, and seamless access to data.
By developing a culture of collective mindfulness, HROs experience fewer-than-anticipated accidents or events of harm despite the inherent risks of their operations. Team members are encouraged to look for and report small issues or unsafe conditions before they turn into significant problems. Healthcare professionals have access to technologies to double-check procedures, diagnoses, and therapies, while AI systems are applied to report inefficiencies, bottlenecks, and disruptions in care delivery or highlight trends in patient data that humans might overlook.
An HRO’s culture is built on five guiding principles: sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to expertise, and resilience. With such a strategic approach, HROs can handle complex situations, detect errors at a very early stage when they don’t yet cause harm, learn from mistakes, and strengthen evidence-based medical practice.
Safety requires the right resources and teamwork
Building a safe, reliable, and effective healthcare organization starts with ensuring the right resources, designing seamless workflows, and prioritizing leadership that supports an open culture and accelerates learning. There are many approaches to achieving organizational excellence, from design thinking tools that align patient pathways with internal procedures to lean healthcare.
A prerequisite is creating a work environment that minimizes errors “by default.” This means amplifying the right workflows with information networks to enable seamless data flow and monitoring. The next step is fostering a supportive work culture strengthened by three pillars:
- Accountability. Mutual responsibility within a team improves the quality of care and performance. Workers need the space to make decisions independently, but they also need to understand leaders' expectations and accept guidelines. In HROs, accountability is not only about following standards but also about transparency. Minor issues should be solved individually to avoid reporting overload. At the same time, more complex problems must be addressed in teams – including cooperation with technology – to prevent bias and create double-check mechanisms.
- Teamwork and communication. Good teams perform well when every member feels accountable and is part of the collective patient safety intelligence. This requires an “ego-free” culture, clear reporting standards, procedures, and information systems that facilitate access to data and streamline information flows within the organization.
- Psychological safety. Staff members must feel secure when they report issues they witness, even if they are lower in the organization hierarchy. This is particularly relevant for junior doctors who may hesitate to question decisions made by senior colleagues. Leaders must establish structures in which – despite the necessary hierarchies in any hospital or clinic – everyone feels equally responsible for both individual and team performance.
HROs are characterized by organizational empathy, truly cultivating patient-centricity and patient safety. When these values are at the core of daily practice, safety follows as a natural outcome. The right culture must be complemented by a learning system that includes improvement and measurement (evaluation of care quality, reporting mechanisms), continuous learning (courses), and transparency.
Technology is an enabler of patient safety only if it is used
Patient safety – the core of the HRO approach – relies on solid communication networks to ensure that information follows the patient. Doctors should be able to check prior diagnoses and medications in electronic health records and access decision-support tools.
They must be equipped with technology that monitors processes and patient health, but they also have an obligation to use the technology responsibly. This includes making thorough notes in the EHR to capture all relevant data to maximize data value. Notably, healthcare professionals need the power to initiate change. If they see the rationale for a new AI-based system to report sepsis risk or predictive analytics tools to improve the health monitoring of a patient with chronic disease, their opinion should be considered when updating the IT environment.
Yet, technology alone isn’t enough if it isn’t viewed as a tool to achieve patient safety, a trusted assistant. For example, in a 2024 study on AI's influence on diagnostic reasoning (Influence of a Large Language Model on Diagnostic Reasoning: A Randomized Clinical Vignette Study), doctors were divided into two groups: one diagnosed cases independently, and the other used GPT-4 as support. Even though GPT-4 outperformed doctors in terms of diagnosis accuracy, the group with access to AI showed minimal improvement. Part of the reason was that doctors were reluctant to trust AI’s suggestions, in addition to factors like lack of digital literacy and administrative burden.
This shows that HROs must do more than implement new technology – they must ensure that the digital tools are used effectively. This goes again back to the core values of HROs aiming to make a shift from individualism to teamwork, prioritizing trust and collaboration over working in information silos.
HROs require leadership that fosters a safety culture, continuously improves workflows, invests in staff training, and prioritizes data-driven decision-making. This involves setting clear priorities, maintaining an open dialogue with healthcare professionals, and leaving behind paternalism, which has no place in modern medicine.
