Two Contrasting Organizations
Organizational Culture
What Do We Mean By a Culture of Safety?
The Culture of Healthcare Organizations
What Makes a Culture of Safety?


A High Reliability Organization (HRO) is one that is known to be complex and risky, yet safe and effective. This term is often applied to the commercial aviation industry.

Effective teamwork, communication, and shared learning are key components of HROs. It is everyone’s job to watch for failure. Central to the concept of HRO’s is the reliance on the team. Decisions are made by the person with the most direct expertise, not necessarily the team “leader.”

Successful teamwork requires that each team member understand their role and how it interconnects to all the others. Cross-training and a true flat hierarchy are important so each individual can appreciate the needs and skills of the others and make intelligent judgments regarding who should be in charge of a particular issue.

In implementing a system of cross-checking each others’ work, all team members must recognize that questioning is from a mutual desire for safe care, not from lack of trust or respect. The system (hospital, practice, etc.) should address the issue by establishing protocol for handling disagreements about care plans and other issues. When differences arise, a key question is “What harm would result if treatment were withheld until the information needed to administer it safely and under mutual agreement is known?”

In 2000, the Institute of Medicine (IOM) recommended formal training in teamwork for healthcare workers, analogous to the crew resource management (CRM) system used to train pilots. Unfortunately, training programs to improve teamwork skills are a new concept for medicine, and no clearly successful models are yet available for translating this format from aviation to healthcare.



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