Nevertheless, Hopkins (2007) raises
the issue regarding the rigidity of Weick and Sutcliff’s HRO definition whereby
organisations must exhibit all five principles to qualify, when in reality
conditions are not so easily defined, and organisations will display varying
principles to differing degrees (Hopkins, 2007). In other words, HRO’s should
be regarded as a framework, an “ideal type” form which organisations can aspire
to achieve, therefore irradiating previous disputes over whether an
organisation definitively classifies as highly reliable if displaying signs of
progression towards and not the attainment of HRO principles.



With this in mind, there have been numerous attempts to successfully
transfer the core HRO principles to non-military contexts and assess the
applicability of the above ‘reliability enhancing’ processes into meaningful practice
(Lekka, 2012; Psnet, 2017). Gordons (2013) ‘Beyond
the checklist’ suggests that patient safety in health care systems can be
enhanced by adapting and incorporating appropriate HRO principles learned from
aviation safety. The concept of ‘high reliability’ is appealing to healthcare
sectors, most prominently intensive care units, as tasks are also completed
under highly complex and fast-paced environments, where an error has
potentially life-threatening consequences (Christianson, 2011). Evidence
for the re-engineering of health care systems in line with HRO core principles
identified from the literature is apparent in Madsen’s (2006) study of a
Paediatric Intensive care unit (PICU) where increased quality of care combined with enhanced response
times proved to be a direct determinant of reduced mortality rates. The
implementation of staff training as a continuing design feature facilitated a
decentralised decision-making structure whereby nurses were encouraged to play
an active role in patient care decisions (Lekka, 2011). This response was to
the growing recognition that specific expertise’s can vary from shift to shift,
given the multidisciplinary nature of healthcare teams and flexible ‘traditional
hierarchy’ structure (Christianson, 2011). Roberts (2005), suggests that the
implementation of a reward scheme highly influenced a change in the embedded cultural
behaviour of staff, encouraging greater opinion sharing and participation from
all disciplines which ultimately acted to reduced error rates.

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(2015), discusses the implementation of a comprehensive accident reporting
system in a large radiation oncology department whereby errors were ranked by
severity level and examined accordingly. The HRO philosophy of ‘Crisis as Safety’ and ‘preoccupation
with failure’ has been argued to be most valuable for managing errors in
healthcare environments where guided error training and reporting following
accidents enables staff to recognise and correct future errors more
consistently (Wilson, 2005). Similarly, Roberts (2005) found this to be the
case in PICU, where ‘risk perception’ increased through the implementation of
in-service lectures, not only after crisis events but also whilst patients appeared
“physiologically quiet” in order to
effectively respond to any possible ‘latent’ or ‘active’ errors (Roberts,