Nevertheless, Hopkins (2007) raisesthe issue regarding the rigidity of Weick and Sutcliff’s HRO definition wherebyorganisations must exhibit all five principles to qualify, when in realityconditions are not so easily defined, and organisations will display varyingprinciples to differing degrees (Hopkins, 2007). In other words, HRO’s shouldbe regarded as a framework, an “ideal type” form which organisations can aspireto achieve, therefore irradiating previous disputes over whether anorganisation definitively classifies as highly reliable if displaying signs ofprogression towards and not the attainment of HRO principles.   With this in mind, there have been numerous attempts to successfullytransfer the core HRO principles to non-military contexts and assess theapplicability of the above ‘reliability enhancing’ processes into meaningful practice(Lekka, 2012; Psnet, 2017). Gordons (2013) ‘Beyondthe checklist’ suggests that patient safety in health care systems can beenhanced by adapting and incorporating appropriate HRO principles learned fromaviation safety.

The concept of ‘high reliability’ is appealing to healthcaresectors, most prominently intensive care units, as tasks are also completedunder highly complex and fast-paced environments, where an error haspotentially life-threatening consequences (Christianson, 2011). Evidencefor the re-engineering of health care systems in line with HRO core principlesidentified from the literature is apparent in Madsen’s (2006) study of aPaediatric Intensive care unit (PICU) where increased quality of care combined with enhanced responsetimes proved to be a direct determinant of reduced mortality rates. Theimplementation of staff training as a continuing design feature facilitated adecentralised decision-making structure whereby nurses were encouraged to playan active role in patient care decisions (Lekka, 2011). This response was tothe growing recognition that specific expertise’s can vary from shift to shift,given the multidisciplinary nature of healthcare teams and flexible ‘traditionalhierarchy’ structure (Christianson, 2011).

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Roberts (2005), suggests that theimplementation of a reward scheme highly influenced a change in the embedded culturalbehaviour of staff, encouraging greater opinion sharing and participation fromall disciplines which ultimately acted to reduced error rates. Woodhouse(2015), discusses the implementation of a comprehensive accident reportingsystem in a large radiation oncology department whereby errors were ranked byseverity level and examined accordingly. The HRO philosophy of ‘Crisis as Safety’ and ‘preoccupationwith failure’ has been argued to be most valuable for managing errors inhealthcare environments where guided error training and reporting followingaccidents enables staff to recognise and correct future errors moreconsistently (Wilson, 2005).

Similarly, Roberts (2005) found this to be thecase in PICU, where ‘risk perception’ increased through the implementation ofin-service lectures, not only after crisis events but also whilst patients appeared”physiologically quiet” in order toeffectively respond to any possible ‘latent’ or ‘active’ errors (Roberts,2005).