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Manifestations of High-Reliability Principles on Hospital Units With Varying Safety Profiles

A Qualitative Analysis

Mossburg, Sarah E., PhD, RN; Weaver, Sallie J., PhD; Pillari, MarieSarah, BSN, RN; Daugherty Biddison, Elizabeth, MD, MPH

doi: 10.1097/NCQ.0000000000000368

Background: To prevent patient harm, health care organizations are adopting practices from other complex work environments known as high-reliability organizations (HRO).

Purpose: The purpose was to explore differences in manifestations of HRO principles on hospital units with high and low safety performance.

Methods: Focus groups were conducted on units scoring high or low on safety measures. Themes were identified using a grounded theory approach, and responses were compared using qualitative thematic analysis.

Results: High performers indicated proactive responses to safety issues and expressed understanding of systems-based errors, while low performers were more reactive and often focused on individual education to address issues. Both groups experienced communication challenges, although they employed different methods of speaking up.

Conclusion: Some HRO principles were present in the language used by our participants. High performers exhibited greater manifestations of HRO, although HRO alone was insufficient to describe our results. Mindful organizing, which expands on HRO, was a better fit.

Johns Hopkins School of Nursing (Drs Mossburg and Weaver), Johns Hopkins School of Medicine (Drs Weaver and Daugherty Biddison and Ms Pillari), and Armstrong Institute for Patient Safety and Quality (Dr Weaver), Baltimore, Maryland.

Correspondence: Sarah E. Mossburg, PhD, RN, Johns Hopkins School of Nursing, 525 N Wolfe St, Baltimore, MD 21205 (

This study was supported in part by a grant from the National Institutes of Health (NIH) NHLBI (K23HL098452 to the Johns Hopkins University) and a grant from the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded in part by grant number 1KL2TR001077-01 from the National Center for Advancing Translational Sciences (NCATS), a component of the NIH, and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily reflect the official views of the Johns Hopkins ICTR, NCATS, or NIH.

The authors declare no conflicts of interest.

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Accepted for publication: August 12, 2018

Published ahead of print: November 21, 2018

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