High Reliability Organizations, Second Edition

Awarded second place in the 2021 AJN Book of the Year Awards in Professional Issues.

Patient safety and quality of care are critical concerns of healthcare consumers, payers, providers, organizations, health systems, and governments. Although a strong body of knowledge shows that high reliability methods enable the most efficient, safe, and effective care, these methods have yet to be completely implemented across healthcare. According to authors Cynthia Oster and Jane Braaten, nurses—who are on the front line of providing safe and effective care—are ideally situated to drive high reliability.

High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality, Second Edition, equips nurses and healthcare professionals with the tools necessary to establish an error detection and prevention system. This new edition builds on the foundation of the first book with best practices, relevant exemplars, and important discussions about cultural aspects essential to sustainability. New material focuses on:

• High reliability performance during a pandemic
• Organizational learning and tiered safety huddles
• High reliability in infection prevention and ambulatory care
• The emerging field of human factors engineering within healthcare
• Creating a virtual resource toolkit for frontline staff

An instructor's guide, student workbook, and sample chapter are available to download for free on the Sigma Repository.

The EPUB electronic version of this book is fully accessible and in compliance with Section 508, WCAG 2.1 Level A and AA standards, making it compatible with assistive software for readers with print disability.

Table of Contents

• Part 1: High Reliability—The Time Is Now
• Chapter 1: The Need for a Paradigm Shift in Healthcare Quality and Safety Thinking
• Chapter 2: Current Patient Safety Drivers
• Chapter 3: Current Quality Drivers
• Chapter 4: Organizational Culture and the Journey to HRO
• Chapter 5: Safety Leadership: Commitment to High Reliability Organizing
• Part 2: HRO Concepts and Application to Practice: Preoccupation With Failure
• Chapter 6: Using Failure Mode and Effects Analysis to Predict Failure
• Chapter 7: Close Calls and Near Misses: What’s the Big Deal?
• Part 3: HRO Concepts and Application to Practice: Reluctance to Simplify
• Chapter 8: Human Factors Engineering for Reducing and Recovering From Error
• Chapter 9: Root Cause Analysis: A Tool for High Reliability in a Complex Environment
• Chapter 10: Just Culture and the Impact on High Reliability
• Part 4: HRO Concepts and Application to Practice: Sensitivity to Operations
• Chapter 11: Alarm Safety: Working Solutions
• Chapter 12: Innovative Technology, Standardization, and the Impact on High Reliability
• Chapter 13: Tiered Safety Huddles
• Part 5: HRO Concepts and Application to Practice: Deference to Expertise
• Chapter 14: Interprofessional Collaboration
• Chapter 15: Nurses Create Reliable Care by Enhancing Engagement
• Chapter 16: Pediatric Patient Safety: Utilizing Safety Coaching as a Strategy Toward Zero Harm
• Part 6: HRO Concepts and Application to Practice: Resilience
• Chapter 17: Resilience: A Path to HRO
• Chapter 18: Designing Resilience Into the Work Environment
• Chapter 19: Building High Reliability Through Simulation
• Chapter 20: Building Resilience Through Team Training: Rapid Response and In-Hospital Cardiac Arrest Events
• Chapter 21: Sustaining a Culture of Safety: Strategies to Maintain the Gains
• Part 7: Assimilation Into Practice Across the Continuum
• Chapter 22: Application of HRO Strategies to Improve Pain Management and Opioid Safety: The CNS Role
• Chapter 23: Ambulatory Care: The Frontier for High Reliability
• Chapter 24: Applying High Reliability Principles Across a Large Healthcare System to Reduce Patient Falls
• Chapter 25: The Synthesis Among Magnet Recognition Program® Model Components and High Reliability Organization Principles
• Chapter 26: Achieving HRO: The Role of the Bedside Scientist in Research
• Part 8: Translation Into Practice
• Chapter 27: High Reliability Performance During a Pandemic
• Chapter 28: Building a High Reliability Head and Neck Operating Room Team
• Chapter 29: Championing CAUTI Prevention in the ICU/SDU: A Project Demonstrating the Concepts of HROT
• Chapter 30: Overstaying Your Welcome: Decreasing ED Stay for STEMI Patients to Improve Reperfusion Times
• Chapter 31: Telehealth: A Highly Reliable Intervention to Prevent Readmissions
• Chapter 32: Introduction of High Reliability to Frontline Staff: Creating a Virtual Resource Toolkit

About the Authors:

Cynthia A. Oster, PhD, MBA, APRN, ACNS-BC, ANP, FAAN, is a Patient Safety Nurse Scientist at Emory Healthcare and an adjunct Assistant Professor at the Nell Hodgson Woodruff School of Nursing at Emory University, Atlanta, Georgia. With 40 years of experience, she has held research, clinical, educational, and administrative positions throughout her career.

Jane S. Braaten, PhD, APRN, CNS, ANP, CPPS, CPHQ, is a Patient Safety Manager and Nurse Scientist at Centura Health. She has held positions within Centura Health as Director of Cardiology Services, Cardiac and Intensive Care Clinical Nurse Specialist, Cardiac Nurse Practitioner, and Manager/Charge RN/Staff RN of intensive care and telemetry units.