gradient refers to one's position within a group or profession. It was defined first in aviation when it was noted that pilots and copilots did not always communicate effectively in stressful situations if there was a significant difference in their perceived authority. Multiple aviation, aerospace, and industrial incidents have been attributed to authority gradients. This information was used to develop and implement the Crew Resource Management (CRM) training program. The training program focuses on interpersonal communication, leadership, and decision making in the cockpit, with the informal motto “see it, say it, fix it.” CRM is credited with the dramatic safety improvements in the airline industry (Helmreich, Merritt & Wilhelm, 1999) and has been adapted for use in health care and many other industries.
Similarly, the nuclear power industry has worked for many years to improve safety. The Institute of Nuclear Power Operations defines safety culture characteristics, some that are adaptable to the health care environment, and include: everyone is responsible for safety, leaders demonstrate commitment to safety, trust permeates the organization, decision making reflects safety first, a questioning attitude is cultivated, organizational learning is embraced and safety needs constant examination (Institute of Nuclear Power Operations, 2004). The American College of Healthcare Executives and Institute for Healthcare Improvement (IHI) published a blueprint for safety (2014) and is summarized in Table 4.2. These characteristics are essential for cultural transformation and are as applicable for all health care organizations.
Table 4.2 Safety Culture Characteristics
| Establish a vision for safetyBuild trust, respect, and inclusionSelect, develop, and engage your BoardPrioritize safety in the selection and development of leadersLead and reward a just cultureEstablish organization behavior expectations |
Source: Based on American College of Healthcare Executives and Institute for Healthcare Improvement. (2017). Leading a Culture of Safety: A Blueprint for Success. Retrieved from www.osha.gov/shpguidelines/docs/Leading_a_Culture_of_Safety-A_Blueprint_for_Success.pdf
HRO Characteristics
Weick and Sutcliffe (2007) identified five key principles of HROs that are used to this day, summarized in Table 4.3. These characteristics, when present, help an organization to achieve high reliability. Each characteristic is described in detail below.
Table 4.3 HRO Characteristics
| Characteristic | Activities |
|---|---|
| Preoccupation with failure | Pay attention to near‐miss events Look for weaknesses in the delivery of care |
| Reluctance to simplify | Acknowledge the complex nature of health care delivery Focus on the root (true) cause of errors |
| Sensitivity to operations | Develop awareness of how the environment, resources, and supplies impact safety Acknowledge the effect of relationships on safety |
| Commitment to resilience | Anticipate and alleviate errors Work to decrease risk of harm Develop recovery strategies when adverse events occur |
| Deference to expertise | Recognize individuals' knowledge, skill, and expertise Employ teamwork Foster active participation by healthcare providers Eliminate hierarchical thinking Share information |
Source: Patti Ludwig‐Beymer.
Preoccupation with Failure
In preoccupation with failure, nurses and other health care providers are aware that the risk of error is always present. An HRO recognizes that failures can occur and deploys processes to diminish harm. An HRO proactively identifies high risk activities and analyzes all the potential error points in the process. This analysis can be performed as a Failure Modes and Effect Analysis (FMEA), a rigorous process in which a team of clinicians identify and eliminate known and potential failures, errors, or problems before they occur (Hughes, 2008). Failures are prioritized according to the seriousness of the consequences, how frequently they occur, and how easily they can be detected. An FMEA example is provided in Figure 4.2.
Source: Patti Ludwig‐Beymer.
Preoccupation with failure requires that critical information be communicated across time, across the health care team, and across sites of care. For example, a patient may be seen in the Emergency Department (ED) and require admission to the acute care hospital. Prior to transferring the patient, the ED nurse provides a thorough report to the nurse on the receiving unit.
In preoccupation with failure, nurses report questionable or unsafe practices. They notice and learn from near miss safety events and precursor safety events. These events are viewed as early warnings that something is wrong. Nurses recognize when an error can or has occurred, feel confident in stopping unsafe practices, and assume the responsibility for reporting errors or near misses. The organization then uses the reports to correct unsafe processes through rigorous process improvement activities.
Reluctance to Simplify
Reluctance to simplify motivates an organization to understand errors. Nurses in HRO health care facilities focus on drilling down to determine the true cause of error. They challenge the current situation to make health care processes and structures safer. For example, a nurse may fail to check a patient's blood sugar as ordered. Initially, the nurse may just indicate “I forgot.” However, analyzing the situation for contributing factors to this failure helps the organization to find real, root cause, and develop solutions. Multiple factors could have contributed to the failure to check a patient's blood sugar. The patient may have been off the unit for a test. The information may not have been shared at change of shift, or a reminder prompt in the electronic health record (EHR) may have been missing. The necessary supplies and equipment may not have been available. An examination of each of these factors allows an HRO to determine ways to prevent this error.
Reluctance to simplify also requires taking action to eliminate work=arounds, the use of short cuts to streamline care without realizing the potential impact on safety. For example, a national patient safety goal requires the use of hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Nurses may save time by rinsing rather than thoroughly washing their hands. Unfortunately, this increases risk to patients and staff. Leaders in HROs identify and extinguish these types of work‐arounds.
Sensitivity to Operations
Sensitivity to operations acknowledges the complex nature of health care. Factors such as fatigue, distractions, and workload can contribute to unsafe conditions. In HROs, nursing leaders make
