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High‐reliability organizations (HROs) focus on safety; being mindful is pervasive in the culture. Focusing on where the next error may occur allows providers to increase vigilance, establish check lists, or implement other preventions (see Chapter 8). Five principles guide HROs: sensitivity to operations, preoccupation with failure, reluctance to simplify, deference to expertise, and commitment to resilience. HROs apply a systems approach (Oster and Braaten, 2020), shifting error prevention from the individual to a shared accountability across the system. Understanding how the adverse event trajectory occurred provides the opportunity to reconsider protocols, procedures, or other actions that will reduce the possibility of a repeat error. To prevent harm to patients, organizations adopt operational systems and processes that minimize risk and focus on maximizing interception of errors before harm occurs (Sherwood and Armstrong, 2020).

Simplifying and standardizing processes for reliable results are key components of HROs. Reliability is expecting to get the same result each time an action occurs; therefore, a reliable system seeks to have defect‐free operations in spite of a high‐risk environment such as preventing wrong‐site surgery or health care–acquired infections. For example, the reduction in CLABSI (central line arterial blood stream infection) events came from following an evidence‐based standardized care process.

Reliability has economic consequences. Hospital reimbursement is increasingly tied to quality and safety outcomes (see Chapter 2). Hospitals may not be reimbursed for patient harms such as hospital‐acquired infections, therefore reliable procedures are needed to ensure adherence to hand‐washing procedures, evidence‐based catheter insertion and care guidelines, and other evidence‐based best practices.