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In Chapter 9, I 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: an 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 few years, the patient safety world has embraced the concept of HROs. Personally, I find the concept intriguing, but wonder whether it is something of a healthcare “MacGuffin.” Legendary film director Alfred Hitchcock used to love to insert a MacGuffin—a plot device, such as a piece of jewelry, a stack of important-looking papers, or a suitcase, that “motivates the characters or advances the story, but the details of which are of little or no importance otherwise”—into his films. Similarly, when I hear a healthcare organization pledge to become an HRO, I wonder whether they are trying to advance their own “patient safety story” without committing themselves to an actionable or measurable target. In this, I find myself agreeing with British safety expert Charles Vincent, who 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...

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