A mindful infrastructure for increasing reliability.

Abstract

Traditional analyses of adverse medical events and errors have focused on individuals. The search for a cause typically has stopped at the person closest to the accident who, it is determined after the fact, could have acted differently in a way that would have led to a different outcome. Traditional approaches have focused on people as unreliable components. But the new look at error has shifted its focus from individuals to the systems in which these individuals are situated. I want to add to this discussion by reporting on an analysis of non-medical organizations called "high reliability organizations" (or HROs) that incur similar temptations to blame individuals rather than systems, but have been successful in focusing attention on systems. The point of this discussion is to suggest that the ways in which HROs do this are instructive for medical organizations whose goal is fewer adverse events.