Organization-wide approaches to patient safety

Figures & data

Table 1 Levels of reliability

Level	Reliability	Success	Opportunities per failure	Real-world example	Health care example
Chaotic	<10^-1	<90%	<10	Annual mortality if >90 years old	Achievement of best practice processes in outpatient care
1	10^-1	90%	10	Mortality of climbing Mt Everest	Achievement of best practice processes in inpatient care
2	10^-2	99%	100	Mortality of Grand Prix Racing	Deaths in risky surgery (ASA 3–5)
3	10^-3	99.9%	1,000	Helicopter crashes	Deaths in general surgery
4	10^-4	99.99%	10,000	Mortality of canoeing	Deaths in routine anesthesia
5	10^-5	99.999%	100,000	Chartered flight crashes	Deaths from blood transfusions
6	10^-6	99.9999%	1,000,000	Commercial airline crashes	–

Notes: Reproduced with permission from Niedner MF, Muething SE, Sutcliffe KM. The high-reliability pediatric intensive care unit. Pediatr Clin North Am. 2013;60(3):563–580.⁵⁵

Abbreviation: ASA, American Society of Anesthesiologists.

Table 2 System characteristics as they relate to differing levels of reliability

Low reliability (Generally more basic and inconsistent)	←	Reliability	→	High reliability (Generally more robust and effective)
• Individual preference prevails		• Personnel informed by reliability science		• Sophisticated organizational design
• Intent to perform well		• Implementation of human factors		• Integrated hierarchies, processes, teams
• Individual excellence rewarded		• Standardization of processes is the norm		• Error-proofing: forced function,
• Human vigilance for risk, error, harm		• Ambiguities in standard work eliminated		shutdown
• Hard work, trying harder after failures		• “work-around” solutions eliminated		• Failure modes and effects analysis
• Codified policies, procedures, guidelines		• Reminders and decision support built-in		• Routine simulation for training/reinforcing
• Personal checklists		• Standard checklists (real-time compliance)		• Strong teamwork climate
• Retrospective performance feedback		• Good habits/behaviors leveraged		• Strong safety culture
Didactic training/retraining Awareness-raising Basic standardization (equipment, brands, forms)		Error-proofing: warnings, sensory alerts Deliberate redundancy in critical steps Key tasks are scheduled/assigned Some simulation training for emergencies Real-time performance feedback		Staff perception of psychological safety Preoccupation with failure Reluctance to simplify interpretations Sensitivity to operations Deference to expertise Commitment to resilience

Notes: Reproduced with permission from Niedner MF, Muething SE, Sutcliffe KM. The high-reliability pediatric intensive care unit. Pediatr Clin North Am. 2013;60(3):563–580.⁵⁵

Table 3 Barriers to achieving high reliability in health care

Barriers to achieving high reliability in health care

Acceptance of limitations on maximum performance

Abandonment of professional autonomy

Transition from the mindset of craftsman to that of an equivalent actor

Need for system-level arbitration to optimize safety strategies

The need to simplify professional rules and regulations

Niedner MF, Muething SE, Sutcliffe KM. The high-reliability pediatric intensive care unit. Pediatr Clin North Am. 2013;60(3):563–580.

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