High reliability organizations lessons from

Roberts K.H., Bea R., 2001. Must accidents happen Lessons from high-reliability organizations, Academy of Management Executive Vol. 15 (3), pp. 70-79. 

The study of patient safety is the study of complexity. The study of complexity invites us to understand key concepts that can be applied to patient safety. Basic concepts from the fleld of patient safety are sharp and blunt end active and latent failure the Swiss Cheese Model of Accident Causation slips, lapses, and mistakes and hindsight bias and the fundamental attribution error. Key concepts from organizational analysis, such as normalization of deviance, diffusion of responsibility, tightly coupled work processes, and sensemaking, introduce practical lessons from high-reliability organizations. Application of specific lessons to health care are explored in Chapter Five. 

There are numerous examples of how health care organizations have begun to successfully adapt concepts from high-reliability organizations, but there are considerable forces that present barriers to achieving high reliability performance. As health care leaders begin to apply the lessons from HROs, they need to anticipate these barriers and plan to address them. 

Chapter Five, Import New Knowledge and Skills, translates concepts from safety science and lessons from high-reliability organizations into practical applications for health care. 

We envision a time in the near future when regulators and internal teams under siege will be replaced by expert teams assembled from multiple sciences to conduct external reviews of health care accidents and near misses in pursuit of high reliability. These teams will share lessons learned publicly and end forever the conspiracy of silence. And no longer will valuable learnings be lost to combat the epidemic of our time medical accident. After all, if lethal medical accidents can occur in our best institutions, accidents can happen anywhere, and no organization is immune. 

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