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We describe important and common management and labor needs across more than 80 federal agencies as identified by the annual Federal Employee Viewpoint Survey (FEVS) and offer evidence-based interventions for addressing them based on organizational science research. Our recommendations have the synergistic goals of improving employee wellbeing, employee productivity, and agency performance and innovation, which will result in increased agency efficiency and effectiveness for the taxpayer. Specifically, we describe empirical findings and offer suggestions for interventions to improve (a) employee motivation through engagement, empowerment, and embeddedness; (b) employee voice; and (c) within- and across-unit cooperation, communication, and collaboration. We offer recommendations that are sufficiently general to be relevant to many agencies, while also being concrete and actionable. We also offer suggestions for associated research that could be conducted in federal agencies interested in these topics.

We describe important and common management and labor needs across more than 80 federal agencies as identified by the annual Federal Employee Viewpoint Survey (FEVS) and offer evidence-based interventions for addressing them based on organizational science research. Our recommendations have the synergistic goals of improving employee wellbeing, employee productivity, and agency performance and innovation, which will result in increased agency efficiency and effectiveness for the taxpayer. Specifically, we describe empirical findings and offer suggestions for interventions to improve (a) employee motivation through engagement, empowerment, and embeddedness; (b) employee voice; and (c) within- and across-unit cooperation, communication, and collaboration. We offer recommendations that are sufficiently general to be relevant to many agencies, while also being concrete and actionable. We also offer suggestions for associated research that could be conducted in federal agencies interested in these topics.

Organizational crises have often stimulated scholarly theorizing that has been productive for our field. Rarely, however, are there opportunities to theorize regarding crises that happen in our own professional associations. A crisis experienced by Professor Anita McGahan when she was the President of the Academy of Management, described in an accompanying article, has presented such an opportunity. In this set of nine brief reflections, several scholars have considered how McGahan’s actions with regard to that crisis can be understood conceptually and how they may stimulate development of previously established conceptual perspectives. These reflections make evident that McGahan’s actions cannot be appreciated without recognition of the complex dilemmas to which she was responding. These dilemmas include issues of trustworthy leadership, gendered power, leader voice, sensemaking and learning, organizational identities, psychological contracts, institutional leadership, and “good bureaucracy”.

BACKGROUND: Evidence that medical error is a systemic problem requiring systemic solutions continues to expand. Developing a 'safety culture' is one potential strategy toward improving patient safety. A reliable and valid self-report measure of safety culture is needed that is both grounded in concrete behaviors and is positively related to patient safety. OBJECTIVE: We sought to develop and test a self-report measure of safety organizing that captures the behaviors theorized to underlie a safety culture and demonstrates use for potentially improving patient safety as evidenced by fewer reported medication errors and patient falls. SUBJECTS: A total of 1685 registered nurses from 125 nursing units in 13 hospitals in California, Indiana, Iowa, Maryland, Michigan, and Ohio completed questionnaires between December 2003 and June 2004. RESEARCH DESIGN: The authors conducted a cross-sectional assessment of factor structure, dimensionality, and construct validity. RESULTS: The Safety Organizing Scale (SOS), a 9-item unidimensional measure of self-reported behaviors enabling a safety culture, was found to have high internal reliability and reflect theoretically derived and empirically observed content domains. The measure was shown to discriminate between related concepts like organizational commitment and trust, vary significantly within hospitals, and was negatively associated with reported medication errors and patient falls in the subsequent 6-month period. CONCLUSIONS: The SOS not only provides meaningful, behavioral insight into the enactment of a safety culture, but because of the association between SOS scores and reported medication errors and patient falls, it also provides information that may be useful to registered nurses, nurse managers, hospital administrators, and governmental agencies. [ABSTRACT FROM AUTHOR]

Background: Preventable harms from medications are significant threats to patient safety in community settings, especially among ambulatory older adults on multiple prescription medications. Patients may partner with primary care professionals by taking on active roles in decisions, learning the basics of medication self-management, and working with community resources., Objective: This study aims to assess the impact of a set of patient partnership tools that redesign primary care encounters to encourage and empower patients to make more effective use of those encounters to improve medication safety., Methods: The study is a nonrandomized, cross-sectional stepped wedge cluster-controlled trial with 1 private family medicine clinic and 2 public safety-net primary care clinics each composing their own cluster. There are 2 intervention sequences with 1 cluster per sequence and 1 control sequence with 1 cluster. Cross-sectional surveys will be taken immediately at the conclusion of visits to the clinics during 6 time periods of 6 weeks each, with a transition period of no data collection during intervention implementation. The number of visits to be surveyed will vary by period and cluster. We plan to recruit patients and professionals for surveys during 405 visits. In the experimental periods, visits will be conducted with two partnership tools and associated clinic process changes: (1) a 1-page visit preparation guide given to relevant patients by clinic staff before seeing the provider, with the intention to improve communication and shared decision-making, and (2) a library of short educational videos that clinic staff encourage patients to watch on medication safety. In the control periods, visits will be conducted with usual care. The primary outcome will be patients' self-efficacy in medication use. The secondary outcomes are medication-related issues such as duplicate therapies identified by primary care providers and assessment of collaborative work during visits., Results: The study was funded in September 2019. Data collection started in April 2023 and ended in December 2023. Data was collected for 405 primary care encounters during that period. As of February 15, 2024, initial descriptive statistics were calculated. Full data analysis is expected to be completed and published in the summer of 2024., Conclusions: This study will assess the impact of patient partnership tools and associated process changes in primary care on medication use self-efficacy and medication-related issues. The study is powered to identify types of patients who may benefit most from patient engagement tools in primary care visits., Trial Registration: ClinicalTrials.gov NCT05880368; https://clinicaltrials.gov/study/NCT05880368., International Registered Report Identifier (irrid): DERR1-10.2196/57878., (©Yan Xiao, Kimberley G Fulda, Richard A Young, Z Noah Hendrix, Kathryn M Daniel, Kay Yut Chen, Yuan Zhou, Jennifer L Roye, Ludmila Kosmari, Joshua Wilson, Anna M Espinoza, Kathleen M Sutcliffe, Samantha I Pitts, Alicia I Arbaje, Michelle A Chui, Somer Blair, Dawn Sloan, Masheika Jackson, Ayse P Gurses. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 29.04.2024.)

Safety models from disciplines outside of health care have begun to diffuse into the health care safety arena. This article explores high reliability organizing (HRO) theory, which privileges culture as means to adaptively learn and reliably perform. A brief history of the HRO paradigm and factors that contribute to cultures of high reliability is provided, followed by review of existing research to discern which HRO ideas have diffused into research on anesthesiology and perioperative care. High reliability research is growing and concepts seem useful; but there is a long way to go before the benefits of HRO are fully realized., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Our aim was to understand actions by primary care teams to improve medication safety., Methods: This was a qualitative study using one-on-one, semistructured interviews with the questions guided by concepts from collaborative care and systems engineering models, and with references to the care of older adults. We interviewed 21 primary care physicians and their team members at four primary care sites serving patients with mostly low socioeconomic status in Southwest US during 2019-2020. We used thematic analysis with a combination of inductive and deductive coding. First, codes capturing safety actions were incrementally developed and revised iteratively by a team of multidisciplinary analysts using the inductive approach. Themes that emerged from the coded safety actions taken by primary care professionals to improve medication safety were then mapped to key principles from the high reliability organisation framework using a deductive approach., Results: Primary care teams described their actions in medication safety mainly in making standard-of-care medical decisions, patient-shared decision-making, educating patients and their caregivers, providing asynchronous care separate from office visits and providing clinical infrastructure. Most of the actions required customisation at the individual level, such as limiting the supply of certain medications prescribed and simplifying medication regimens in certain patients. Primary care teams enacted high reliability organisation principles by anticipating and mitigating risks and taking actions to build resilience in patient work systems. The primary care teams' actions reflected their safety organising efforts as responses to many other agents in multiple settings that they could not control nor easily coordinate., Conclusions: Primary care teams take many actions to shape medication safety outcomes in community settings, and these actions demonstrated that primary care teams are a reservoir of resilience for medication safety in the overall healthcare system. To improve medication safety, primary care work systems require different strategies than those often used in more self-contained systems such as hospital inpatient or surgical services., Competing Interests: Competing interests: Dr RAY discloses that he is the sole owner of SENTIRE, LLC, which is a novel primary care documentation, coding and billing system. The other authors report no potential competing interests., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We apply the high-reliability organization (HRO) paradigm to the diagnostic process, outlining challenges to enacting HRO principles in diagnosis and offering solutions for how diagnostic process stakeholders can overcome these barriers., Background: Evidence shows that healthcare is starting to organize for higher reliability by employing various principles and practices of HRO. These hold promise for enhancing safer care, but there has been little consideration of the challenges that clinicians and healthcare systems face while enacting HRO principles in the diagnostic process. To effectively deploy the HRO perspective, these barriers must be seriously considered., Method: We review key principles of the HRO paradigm, the diagnostic errors and harms that potentially can be prevented by its enactment, the challenges that clinicians and healthcare systems face in executing various principles and practices, and possible solutions that clinicians and organizational leaders can take to overcome these challenges and barriers., Results: Our analyses reveal multiple challenges including the inherent diagnostic uncertainty; the lack of diagnosis-focused performance feedback; the fact that diagnosis is often a solo, rather than team, activity; the tendency to simplify the diagnostic process; and professional and institutional status hierarchies. But these challenges are not insurmountable-there are strategies and solutions available to overcome them., Conclusion: The HRO lens offers some important ideas for how the safety of the diagnostic process can be improved., Application: The ideas proposed here can be enacted by both individual clinicians and healthcare leaders; both are necessary for making systematic progress in enhancing diagnostic performance.

This initial, exploratory study on gender bias in collaborative medical decision making examined the degree to which physicians' reliance on a team member's patient care advice differs as a function of the gender of the advice giver. In 2018, 283 anesthesiologists read a brief, online clinical vignette and were randomly assigned to receive treatment advice from 1 of 8 possible sources (physician or nurse, man or woman, experienced or inexperienced). They then indicated their treatment decision, as well as the degree to which they relied upon the advice given.The results revealed 2 patterns consistent with gender bias in participants' advice taking. First, when treatment advice was delivered by an inexperienced physician, participants reported replying significantly more on the advice of a man versus a woman, F(1,61) = 4.24, P = .04. Second, participants' reliance on the advice of the woman physician was a function of her experience, F(1,62) = 6.96, P = .01, whereas reliance on the advice of the man physician was not, F(1,60) = 0.21, P = .65.These findings suggest women physicians, relative to men, may encounter additional hurdles to performing their jobs, especially at early stages in their careers. These hurdles are rooted in psychological biases of others, rather than objective features of cases or treatment settings. Cultural stereotypes may shape physicians' information use and decision-making processes (and hinder collaboration), even in contexts that appear to have little to do with social category membership. The authors recommend institutions adopt policies and practices encouraging equal attention to advice, regardless of the source, to help ensure advice taking is a function of information quality rather than the attributes of the advice giver. Such policies and practices may help surface and implement diverse expert perspectives in collaborative medical decision making, promoting better and more effective patient care.

Efforts to improve quality of care and patient safety have concentrated on provider practice and frontline care processes. Little attention has focused on understanding the role that leadership decisions play in creating risk within a health care system. The framework and tool described in this article builds on Reason's construct of latent organizational failure, by assessing the latent risks of leadership decisions, and identifying appropriate mitigation strategies before the implementation of a change. Stakeholders who will be involved in or impacted by the change are engaged in the assessment to more thoroughly explore both technical and cultural risks., (© 2018 American Society for Health Care Risk Management of the American Hospital Association.)

The importance of patient safety has grown tremendously; however, there are insufficient resources dedicated to its practical application. We provide an overview of the framework for addressing patient safety within the Johns Hopkins Health System, which approaches patient safety in the context of risk at the patient, provider, unit, and system levels. We present practical examples of how this approach is applied and highlight the resources needed as well as describe how it fits within the broader quality management infrastructure in the health system on its journey toward high reliability., (© 2018 American Society for Health Care Risk Management of the American Hospital Association.)

Background: Studies show that implementing huddles in healthcare can improve a variety of outcomes. Yet little is known about the mechanisms through which huddles exert their effects. To help remedy this gap, our study objectives were to explore hospital administrator and frontline staff perspectives on the benefits and challenges of implementing a tiered huddle system; and propose a model based on our findings depicting the mediating pathways through which implementing a huddle system may reduce patient harm., Methods: Using qualitative methods, we conducted semi-structured interviews and focus groups to obtain a deeper understanding of the huddle system and its outcomes as implemented in an academic tertiary care children's hospital with 539 inpatient beds. We recruited healthcare providers representing all levels using a snowball sampling technique (10 interviews), and emails, flyers, and paper invitations (six focus groups). We transcribed recordings and analysed the data using established techniques., Results: Five themes emerged and provided the foundational constructs of our model. Specifically we propose that huddle implementation leads to improved efficiencies and quality of information sharing, increased levels of accountability, empowerment, and sense of community, which together create a culture of collaboration and collegiality that increases the staff's quality of collective awareness and enhanced capacity for eliminating patient harm., Conclusions: While each construct in the proposed model is itself a beneficial outcome of implementing huddles, conceptualising the pathways by which they may work allows us to design ways to evaluate other huddle implementation efforts designed to help reduce failures and eliminate patient harm.

In health care, reliability is the measurable capability of a process, procedure, or health service to perform its intended function in the required time under actual or existing conditions (as opposed to the ideal circumstances under which they are often studied). This article outlines the current state of reliability in a clinical context, discusses general principles of reliability, and explores the characteristics of high-reliability organizations as a desirable future state for pediatric critical care., (Published by Elsevier Inc.)

Background: This is a study of a method of mortality review, adopted by the Michigan Society of Thoracic and Cardiovascular Surgeons, to enhance understanding of mortality and potentially avoidable deaths after cardiac surgery, utilizing a voluntary statewide database., Methods: A system to categorize mortality was developed utilizing a phase of care mortality analysis approach as well as providing criteria to classify mortality as potentially "avoidable." For each mortality, the operating surgeon categorized a cardiac surgery mortality trigger into 1 of 5 time frames: preoperative, intraoperative, intensive care unit (ICU), postoperative floor, and discharge., Results: A total of 53,674 adult cardiac operations were performed from January 1, 2006 to June 30, 2010 with a crude mortality of 3.5% (1,905 of 53,674). Of the mortalities analyzed, 35% (618 of 1,780) were preoperative, 25% (451 of 1,780) were ICU, 19% (333 of 1,780) were intraoperative, 11% (198 of 1,780) were floor, and 10% (180 of 1,780) were discharge phase. "Avoidable" mortality triggers occurred in 53% (174 of 333) of the intraoperative, 41% (253 of 618) and (184 of 451) of the preoperative and ICU phases, 42% (83 of 198) of the floor, and 19% (35 of 180) of the discharge phase. Overall potentially avoidable mortality was 41% (729 of 1780). Thirty-six percent (644 of 1,780) of the mortalities were coronary artery bypass grafting patients and 29% (188 of 644) of these were in the preoperative phase, with a mean predicted risk of 16%., Conclusions: This analysis identifies the occurrence of potentially avoidable mortalities in the 4 hospital phases of care, with the largest absolute number of avoidable mortalities occurring in the preoperative phase. A focus on these phases of care provides significant opportunity for quality improvement initiatives. Utilizing phase of care mortality analysis stimulates surgeons and hospitals to develop and refine mortality reviews and provides a structured statewide platform for discussion, education, quality improvement, and enhanced outcomes., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Context: Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on the joint benefits of safety organizing and other contextual factors that help foster safety., Objectives: Although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety. Specifically, we examined the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors., Subjects: A total of 1033 RNs and 78 nurse managers in 78 emergency, internal medicine, intensive care, and surgery nursing units in 10 acute-care hospitals in Indiana, Iowa, Maryland, Michigan, and Ohio who completed questionnaires between December 2003 and June 2004., Research Design: Cross-sectional analysis of medication errors reported to the hospital incident reporting system for the 6 months after the administration of the survey linked to survey data on safety organizing, trust in manager, use of care pathways, and RN characteristics and staffing., Results: Multilevel Poisson regression analyses indicated that the benefits of safety organizing on reported medication errors were amplified when paired with high levels of trust in manager or the use of care pathways., Conclusions: Safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system.

Academic and professional disciplines, such as organisation and management theory, psychology, sociology and engineering, have, for years, grappled with the multidisciplinary issues of safety and accident prevention. However, these ideas are just beginning to enrich research on safety in medicine. This article examines a domain of research on system safety - the High Reliability Organization (HRO) paradigm. HROs operate in hazardous conditions, but have fewer than their fair share of adverse events. HROs are committed to safety at the highest level and adopt a special approach to its pursuit. The attributes and operating dynamics of the best HROs provide a template on which to better understand how safe and reliable performance can be achieved under trying conditions, and this may be useful to researchers and caregivers who seek to improve safety and reliability in health care., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Aircraft carriers, electrical power grids, and wildland firefighting, though seemingly different, are exemplars of high reliability organizations (HROs)--organizations that have the potential for catastrophic failure yet engage in nearly error-free performance. HROs commit to safety at the highest level and adopt a special approach to its pursuit. High reliability organizing has been studied and discussed for some time in other industries and is receiving increasing attention in health care, particularly in high-risk settings like the intensive care unit (ICU). The essence of high reliability organizing is a set of principles that enable organizations to focus attention on emergent problems and to deploy the right set of resources to address those problems. HROs behave in ways that sometimes seem counterintuitive--they do not try to hide failures but rather celebrate them as windows into the health of the system, they seek out problems, they avoid focusing on just one aspect of work and are able to see how all the parts of work fit together, they expect unexpected events and develop the capability to manage them, and they defer decision making to local frontline experts who are empowered to solve problems. Given the complexity of patient care in the ICU, the potential for medical error, and the particular sensitivity of critically ill patients to harm, high reliability organizing principles hold promise for improving ICU patient care.

Purpose: To explore the significant emotional challenges facing resident physicians in the setting of medical mishaps, as well as their approaches to coping with these difficult experiences., Method: Twenty-six resident physicians were randomly selected from a single teaching hospital and participated in in-depth qualitative interviews. Transcripts were analyzed iteratively and themes identified., Results: Residents expressed intense emotional responses to error events. Poor patient outcomes and greater perceived personal responsibility were associated with more intense reactions and greater personal anguish. For the great majority of residents, their ability to cope with these events was dependent on a combination of reassurance and opportunities for learning. Interactions with medical colleagues and supervisory physicians were critical to this coping process., Conclusions: Medical mishaps have a profound impact on resident physicians by eliciting intense emotional responses. It is critical that resident training programs recognize the personal and professional significance of these experiences for young physicians. Moreover, resident education must support the development of constructive coping skills by facilitating candid discussion and learning subsequent to these events.

Background: The study of patient safety can benefit from greater methodological diversity to improve scientific knowledge and to increase the effectiveness and tailoring of strategies aimed at improving it., Methodological Diversity to Better Capture Causal Mechanisms and Processes: Additional methods for studying patient safety and errors to reflect the complexity of what goes on within health care organizations should be made routine. Interviews, focus groups, and observation--the predominant methods used in qualitative research--are infrequently used in health services research, generally and specifically in the study of errors and patient safety. However, they offer several advantages over quantitative designs. They often are less expensive and quicker to implement; they may not need a lot of advance work; and they can be used to study retrospectively a particular failure event, outcome, or situation., Action Steps: Organizations can use an action agenda to better implement and promote the use of qualitative methods. Implementing these action steps can help achieve the attributes-trust, honesty, communication, participation, and efficiency-necessary to facilitate the qualitative approach in health care work settings., Summary and Conclusion: Qualitative approaches should be used in studying patient safety as a complement to (not a substitute for) quantitative approaches. They can be implemented more easily in organizations through structural and cultural adjustments that provide a more supportive foundation for this work.

Background: Studies before and since the 1999 Institute of Medicine report have noted the limitations of using medical record reporting for reliably quantifying and understanding medical error. Quantitative macro analyses of large datasets should be supplemented by small-scale qualitative studies to provide insight into micro-level daily events in clinical and hospital practice that contribute to errors and adverse events and how they are reported., Design: The study design involved semistructured face-to-face interviews with residents about the medical errors in which they recently had been involved and included questions regarding how those errors were acknowledged., Objective: This paper reports the ways in which medical error is or is not reported and residents' responses to a perceived medical error., Participants: Twenty-six residents were randomly sampled from a total population of 85 residents working in a 600-bed teaching hospital., Measurements: Outcome measures were based on analysis of cases residents described. Using Ethnograph and traditional methods of content analysis, cases were categorized as Documented, Discussed, and Uncertain., Results: Of 73 cases, 30 (41.1%) were formally acknowledged and Documented in the medical record; 24 (32.9%) were addressed through Discussions but not documented; 19 cases (26%) cases were classified as Uncertain. Twelve cases involved medication errors, which were acknowledged in different categories., Conclusions: The supervisory discussion, the informal discussion, and near-miss contain important information for improving clinical care. Our study also shows the need to improve residents' education to prepare them to recognize and address medical errors.

Purpose: To describe how communication failures contribute to many medical mishaps., Method: In late 1999, a sample of 26 residents stratified by medical specialty, year of residency, and gender was randomly selected from a population of 85 residents at a 600-bed U.S. teaching hospital. The study design involved semistructured face-to-face interviews with the residents about their routine work environments and activities, the medical mishaps in which they recently had been involved, and a description of both the individual and organizational contributory factors. The themes reported here emerged from inductive analyses of the data., Results: Residents reported a total of 70 mishap incidents. Aspects of "communication" and "patient management" were the two most commonly cited contributing factors. Residents described themselves as embedded in a complex network of relationships, playing a pivotal role in patient management vis-à-vis other medical staff and health care providers from within the hospital and from the community. Recurring patterns of communication difficulties occur within these relationships and appear to be associated with the occurrence of medical mishaps., Conclusion: The occurrence of everyday medical mishaps in this study is associated with faulty communication; but, poor communication is not simply the result of poor transmission or exchange of information. Communication failures are far more complex and relate to hierarchical differences, concerns with upward influence, conflicting roles and role ambiguity, and interpersonal power and conflict. A clearer understanding of these dynamics highlights possibilities for appropriate interventions in medical education and in health care organizations aimed at improving patient safety.

Although research has suggested that teams can differ in the extent to which they encourage proactive learning and competence development among their members (a team learning orientation), the performance consequences of these differences are not well understood. Drawing from research on goal orientation and team learning, this article suggests that, although a team learning orientation can encourage adaptive behaviors that lead to improved performance, it is also possible for teams to compromise performance in the near term by overemphasizing learning, particularly when they have been performing well. A test of this proposition in a sample of business unit management teams provides strong support. The results confirm that an appropriate emphasis on learning can have positive consequences for team effectiveness.

Many business thinkers believe it's the role of senior managers to scan the external environment to monitor contingencies and constraints, and to use that precise knowledge to modify the company's strategy and design. As these thinkers see it, managers need accurate and abundant information to carry out that role. According to that logic, it makes sense to invest heavily in systems for collecting and organizing competitive information. Another school of pundits contends that, since today's complex information often isn't precise anyway, it's not worth going overboard with such investments. In other words, it's not the accuracy and abundance of information that should matter most to top executives--rather, it's how that information is interpreted. After all, the role of senior managers isn't just to make decisions; it's to set direction and motivate others in the face of ambiguities and conflicting demands. Top executives must interpret information and communicate those interpretations--they must manage meaning more than they must manage information. So which of these competing views is the right one? Research conducted by academics Sutcliffe and Weber found that how accurate senior executives are about their competitive environments is indeed less important for strategy and corresponding organizational changes than the way in which they interpret information about their environments. Investments in shaping those interpretations, therefore, may create a more durable competitive advantage than investments in obtaining and organizing more information. And what kinds of interpretations are most closely linked with high performance? Their research suggests that high performers respond positively to opportunities, yet they aren't overconfident in their abilities to take advantage of those opportunities.

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.