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Department: Guest Editorial

Achieving zero harm

Editor(s): Palatnik, AnneMarie DNP, RN, ACNS-BC

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doi: 10.1097/01.CCN.0000612844.19763.16
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Since the publication of the Institute of Medicine's two landmark reports, To Err is Human: Building a Safer Health System in 1999 and Crossing the Quality Chasm: A New Health System for the 21st Century in 2001, organizations have worked diligently to improve safety, but we still have a long way to go.1,2 Makary and Daniel more recently found that healthcare errors and omissions accounted for 251,000 deaths each year.3 For this reason, many organizations are striving to become high reliability organizations (HROs) and cause zero harm.

HROs have five characteristic ways of thinking to anticipate, detect, and respond early to problems to prevent dangerous consequences: preoccupation with failure, sensitivity to operations, reluctance to simplify, commitment to resilience, and deference to expertise.4

The first three characteristics are principles of anticipation that prevent errors. HROs preoccupied with failure predict challenges in the ever-changing healthcare environment. Facilities sensitive to operations stress ongoing interaction between leadership and frontline staff to seek system safety. HROs reluctant to simplify look beyond surface explanations of how or why work processes succeed or fail.4

Commitment to resilience and deference to expertise are principles of containment when unfortunate consequences do occur. HROs committed to resilience complete rapid assessments and implement rapid responses to difficult situations. Facilities that defer to expertise allow decision-making to occur at the level of those with the most knowledge regardless of rank.4

According to Clapper and colleagues, HROs also use five universal reliability skills: attention on task, communicating effectively, think critically, adherence to protocols, and speaking up for patients and teammates.5 Attention on task occurs by using the self-check tool STAR (Stop-Think-Act-Review). Communicating effectively ensures that we hear and understand things correctly. Tools include the SBAR, 3-way read backs and repeat backs, and asking clarifying questions. Thinking critically requires a questioning attitude and validation and verification of information. Adherence to protocols helps prevent deviation and variation. Speaking up provides risk awareness and escalation of concerns. One useful tool is the ARCC: Ask a question, Request a change, voice a Concern, and if no success, escalate through the leadership Chain of command.

These principles and tools are essential to achieving zero harm. Every patient deserves perfect care, and every critical care nurse deserves to work in an environment where they can deliver perfect care.


AnneMarie Palatnik, DNP, RN, ACNS-BC
Assistant Vice President of Clinical Learning, Academic Affiliations, and Research Virtua Health, Mount Laurel, N.J.


1. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
3. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.
4. Agency for Healthcare Research and Quality (AHRQ). Patient safety primer: high reliability. 2019.
5. Clapper C, Merlino J, Stockmeier C. Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare. New York, NY: McGraw Hill; 2019.
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