Implementing HRO Principles under Stress: A Hospital's Journey toward High Reliability.

Introduction: High reliability organization principles are an established approach to reducing risk in highly complex environments. Our hospital recognized an opportunity to integrate these principles during the disruption of the COVID-19 pandemic. Methods: This work took place at our quaternary pediatric hospital. Interventions fell within 3 categories: optimizing structure for success, measurement and transparency, and assigning accountability and empowering all. Our outcome measures of interest were several significant safety events meeting predefined definitions per month, and our process metric was the total number of events reported in our safety event reporting system. Results: Following multiple cycles of interventions, the U chart of high-impact safety events per month demonstrated a centerline shift from 5.6 to 8.5 events per 10,000 adjusted patient days in April 2021 and a subsequent shift down to 5.9 events per 10,000 adjusted patient days in March 2023. A U chart of safety reports showed a decrease from 47.2 to 29.9 events per 1,000 adjusted patient days in April 2020, subsequently increasing to 39.9 events per 1,000 adjusted patient days in March 2022. Conclusions: Through interventions focused on high reliability organization principles, our hospital successfully increased the detection of high-impact safety events and then decreased the number of these serious events. We implemented these interventions despite the disruptions of the COVID-19 pandemic, and they have served as a protective mechanism during subsequent system stressors.