In Chapter 9, we discussed the tragic collision of two 747s on a foggy morning in Tenerife, the crash that vividly illustrated to everyone in the field of commercial aviation the risks associated with steep and unyielding authority gradients. In response to Tenerife and similar accidents, aviation began a series of training programs, generally called “crew resource management” or “cockpit resource management” (CRM) programs, designed to train diverse crews in communication and teamwork. Some of these programs also incorporate communication skills, such as training in Situation, Background, Assessment, and Recommendations (SBAR) and briefing/debriefing techniques (Chapter 9). There is widespread agreement that these programs helped transform the culture of aviation, a transformation that was largely responsible for the remarkable safety record of commercial airlines over the past generation (Figure 9-1).
As the healthcare field began to tackle patient safety, it naturally looked to other organizations that seemed to have addressed their error problems effectively.1 The concept of high reliability organizations (HROs) became shorthand for the relatively mistake-free state enjoyed by airlines, computer chip manufacturers, nuclear power plants, and naval aircraft carriers—but certainly not healthcare organizations.2,3 According to Weick and Sutcliffe, HROs share the following characteristics:2
Preoccupation with failure: the acknowledgment of the high-risk, error-prone nature of an organization's activities and the determination to achieve consistently safe operations.
Commitment to resilience: the development of capacities to detect unexpected threats and contain them before they cause harm, or to recover from them when they do occur.
Sensitivity to operations: attentiveness to the issues facing workers at the frontline, both when analyzing mistakes and in making decisions about how to do the work. Management units at the frontline are given some autonomy in identifying and responding to threats, rather than being forced to work under a rigid top-down approach.
A culture of safety: in which individuals feel comfortable drawing attention to potential hazards or actual failures without fear of censure from management.
Over the past decade, the patient safety world has embraced the concept of HROs. While conceptually attractive, one wonders whether organizations that commit themselves to become a HRO (as many do) are embracing a vague, albeit laudatory, goal without committing themselves to any actionable or measurable targets. As British safety expert Charles Vincent wrote, “Put simply, reading the HRO literature offers a great deal of inspiration, but little idea of what to do in practice to enhance safety.”4,5
This hints at an overarching challenge we face as we enter the crucial but hazy world of safety culture, which can sometimes feel like the weather—everybody talks about it but nobody does anything about it. When it comes to safety culture, everyone seems to have an opinion. As with many complex matters in life, the truth lies somewhere between the commonly polarized viewpoints. Is a safe culture ...