The safety culture in healthcare organizations is a fundamental concept to ensure the quality of care and patient safety. With the increasing complexity of healthcare, it becomes essential to adopt practices and principles that promote a safe and efficient environment. High Reliability Organizations (HROs) offer a set of principles that can be applied in healthcare organizations to achieve high levels of safety and reliability.

Healthcare organizations are considered high-risk in the context of HROs due to factors that directly influence their operations and outcomes. Here are some of the main reasons:

  • Critical Nature of the Services Provided;
  • Complexity of Operations;
  • Dynamic and Unpredictable Environment;
  • Diversity of Conditions;
  • Human Error;
  • Dependency on Technologies;
  • Complex Interactions among Multidisciplinary Teams.

Characteristics of a Safety Culture
A strong safety culture is characterized by elements that interrelate to create an environment where patient safety is paramount. Some of the main characteristics include:

  • Priority on safety: In a safety culture, safety is prioritized in all decisions and actions. This includes resource allocation, training, and the development of policies and procedures.
  • Open communication: Clear and open communication is paramount for identifying and resolving safety issues. Teams should feel comfortable reporting errors and adverse events without fear of reprisal.
  • Continuous Learning: Organizations should be committed to continuous learning and constant improvement. This includes incident analysis, regular audits, and the implementation of evidence-based improvements.
  • Engaged Leadership: Visible and engaged leadership are essential for promoting and maintaining a safety culture. Leaders should demonstrate commitment to safety and inspire their teams to do the same.
  • Fair Accountability: A culture of fair accountability recognizes that most errors result from systemic failures rather than individuals. Organizations should focus on improving systems and processes rather than punishing team members.

Principles of HROs
HROs are organizations that operate in complex and high-risk environments but manage to maintain consistently low levels of accidents and errors. Five core principles guide these organizations:

  • Concern with Failures: HROs are constantly vigilant in identifying and correcting minor failures before they become major issues. This involves creating a culture where errors are reported and thoroughly analyzed.
  • Reluctance to Simplify: Instead of seeking simplistic solutions to complex problems, HROs recognize the complexity of their operations and seek to fully understand it before taking action.
  • Sensitivity to Operations: HROs maintain a high situational awareness, ensuring that all team members are attentive to actual working conditions and potential risks.
  • Commitment to Resilience: Resilience is the ability to respond quickly and effectively to unexpected events. HROs train their teams to be adaptable and prepared to deal with unforeseen
  • events. Valuing Experience: When problems arise, HROs rely on experts with more knowledge, regardless of their hierarchical position, to make critical decisions.

Contributions of HRO Principles to the Safety Culture

The principles of HROs are essential for building and maintaining a safety culture in healthcare organizations. These principles promote continuous vigilance to detect and correct failures before they cause harm, encourage detailed and comprehensive analysis of incidents, develop the ability to respond quickly and effectively to emergencies, and value the specialized knowledge of professionals. Table 1 shows the main contributions.


Table 1: Contributions of HRO principles to the safety culture

Principle of HROs Contributions to the Safety Culture
Concern with Failure
  • Implements continuous monitoring systems to detect issues before they escalate, promoting a culture of constant vigilance.
  • Encourages the reporting of incidents and near misses without fear of reprisal, creating an environment where professionals feel safe to report issues and collaborate in finding solutions.
Reluctance to Simplify
  • Promotes detailed and comprehensive analysis of incidents to identify all possible causes, avoiding superficial solutions.
  • Encourages the participation of multidisciplinary teams in problem analysis, ensuring that multiple perspectives and specialized knowledge are considered.
Sensitivity to Operations
  • Implements regular safety monitoring, where leaders observe and discuss practices with the team, identifying potential risks in real time.
  • Utilizes monitoring technologies to maintain constant surveillance over performance and safety indicators, allowing for quick responses to any anomalies.
Commitment to Resilience
  • Provides regular training in resilience and emergency response, ensuring that all employees know how to act in critical situations.
  • Develops and regularly tests contingency plans for various failure scenarios, ensuring that the organization can maintain continuity of care even under adverse conditions.
Valuing Experience
  • Establishes decision-making structures that allow experts to make quick decisions during emergencies, improving the accuracy and effectiveness of responses.
  • Promotes a culture where expertise is respected and valued, encouraging cooperation among different hierarchical levels and specialties.


Studies show the positive outcomes achieved by healthcare organizations after adopting the principles of HROs. The article Evidence Brief: Implementation of High Reliability Organization Principles highlights significant reductions in serious safety events, ranging from 55% to 100%. For example, the Ohio Children’s Hospital Association achieved a 55% reduction in serious safety events, while the Nationwide Children’s Hospital achieved an 83% reduction after two years of implementing HRO principles.

The adoption of HRO principles promotes an environment where patient safety is prioritized and maintained. By integrating concerns about failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and the valuing of experience, healthcare organizations can achieve high levels of safety and quality in care. The implementation of these principles, supported by engaged leadership and open communication, creates a solid foundation for a sustainable and effective safety culture.

Author: BIGOLIN, Fernanda. PhD in Technologies and Information Systems, writer, specialist in the practices and principles of High Reliability Organizations (HROs), and in interoperability in the healthcare field.