{"paper_id":"1dee0dfc-94e0-4be5-a52f-4b0cbeea27c3","body_text":"Case study: Understanding whole system safety through theory triangulation of high reliability organization principles and a safety culture framework at one of Canada’s safest hospitals | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Case study: Understanding whole system safety through theory triangulation of high reliability organization principles and a safety culture framework at one of Canada’s safest hospitals Jennifer Yoon, Barbara E. Collins, Aleksandra Zuk This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8800008/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Humber River Health (HRH) is a Toronto Academic Health Sciences Network affiliated community hospital serving a catchment of 850,000 individuals in northwest Toronto. Despite having one of the nation’s busiest emergency departments and admitted volumes in Canada, the hospital leadership, physicians and staff designed and implemented 56 strategies as part of its High Reliability Organization (HRO) journey. Methods Comparison of the hospital’s harm rates versus Canada-wide hospital harm rates were calculated using Chi-squared independence test. As a single-organization case study, document analysis was undertaken to itemize safety strategies, then theoretical triangulation was completed to observe convergence and divergence between the HRO principles of Reason’s Safety Culture Framework. Results The hospital demonstrated a shift in hospital harm rates (2.2%), which was significantly below the provincial (6.1%) and national (6.2%) peer averages (p < 0.05). With respect to theoretical triangulation of the 56 implemented safety strategies, a high level of convergence between the two frameworks were observed at (HRH): HRO principle of pre-occupation with failure (89.3%) with Reason’s learning culture sub-culture (82.1%); HRO principle of sensitivity to operations (76.8%) with Reason’s informed sub-culture (80.4%); HRO principle of reluctance to simplify (67.9%) with Reason’s flexible sub-culture (67.9%); HRO principle of commitment to resilience (64.3%) with Reason’s reporting sub-culture (64.3%). Divergence was observed between the HRO principle of deference to expertise (60.7%) and Reason’s just culture (14.2%). Conclusions We explored the hospital experience and applied analysis of HRO Principles and Reason’s Safety Culture Framework. A high level of alignment between both frameworks were observed, and we encourage organizations on a HRO journey to also conscientiously adopt strategies supporting safety culture as the fifth HRO Principle and support the maturity of whole system safety. Trial Registration: N/A high reliability organization patient safety safety culture Figures Figure 1 Figure 2 Figure 3 Background Introduction to High Reliability Organizations Patient safety is paramount for all health care organizations, which strive to reduce avoidable patient harm and maintain safe systems in a sector known to operate in a high-hazard environment. The field of high reliability organizations (HROs) emerged as Weick and Sutcliffe [1] examined aeronautic and nuclear engineering industries in how they manage daily business despite the potential for catastrophic operational outcomes [1,2]. Five principles emerged that support HRO operations [1,3-6] ( Figure 1 ): sensitivity to operations (maintaining high awareness of changing operational conditions), preoccupation with failure (maintaining heightened sense of vigilance of possible failure), reluctance to simplify (resisting oversimplification of work processes to gain deeper understanding of problems), commitment to resilience (fundamentally understanding the frequent and unpredictable nature of system failures), and deference to expertise (appreciating the persons closest to an incident are the most knowledgeable about it). Over a decade ago, there was a push toward HRO principles in U.S. health care organizations [5]. These principles have led to an expansion of HRO research, particularly in health care settings [3,6]. More recently, the World Health Organization (WHO) developed a Global Patient Safety Action Plan 2021-2030, to support improving patient safety initiatives, highlighting the importance of incorporating high-reliability health systems principles, central to the second strategic objective [7]. In Canada, there is a paucity of research in how HRO principles align with health care organization safety climate, including understanding the principles themselves among those responsible for providing safe patient care [8.9]. Furthermore, the application of these principles are often isolated in action without a strong theoretical foundation [1]. McDonald [10] and Ward [11] argue whole system understanding including individuals, teams, processes, and their dynamic interconnectedness is critical for impacting system-system level change. Hence, the importance of an interdisciplinary academic-healthcare partnership to address complex systems problems is needed, such as the collaboration of healthcare leaders and scholars to enact HRO principles. In this paper, we translate HRO principles in a specific Canadian healthcare organization to reduce preventable harm within the organization. Foundational Framework: Reason’s Safety Culture and Sub-Cultures Healthcare organizations that apply high reliability principles must also carefully consider culture as an operational target alongside HRO principles [3,4]. In fact, the concept of culture has also been referred to as the sixth hallmark of HROs (i.e. organizational mindfulness), as it has been argued as the mechanism to synergistically enable the five original HRO principles [1,12,13]. Since recent discussion of organizational culture has been raised as critical component of high reliability, founded on safety culture theory, Reason’s Safety Culture Framework provides a foundation to examine the underlying cultural components (sub-cultures) that support a mature safety culture [14,15]. Reason’s Safety Culture Framework encompasses five distinct components (i.e., sub-culture contributors) that collectively shape organizational safety culture. Recognized as a highly influential model, Reason’s framework provides organizations with a focus on systems thinking, with its approach to error analysis through the lens of human factors, and its commitment to fostering organizational learning [15]. According to Reason, the five components of organizational safety culture are required to achieve a high reliability culture through the following sub-cultures ( Figure 2 ): informed culture, reporting culture, just culture, flexible culture and learning culture [15]. The knowledge, skills, attitudes, language and coordinating mechanisms inherent in teamwork, and respective culture affords team members the flexibility to operate but also manage the complexity of care from experience [16]. Setting the Context: Humber River Health (HRH) In 2015, a Canadian hospital HRH opened its state-of-the art, fully digital hospital in Toronto – a North American first, encompassing remarkable hospital design guided by the principles of lean, green and digital. Servicing an equity-deserving population of more than 850,000 community members. The digital hospital site is a 1.8 million square-foot acute care facility that brought together patients and staff from two older hospital sites, of which have been converted into Reactivation Care Centres (i.e., where patients who no longer require acute care but awaiting appropriate care facility). Innovations at the new hospital site include the use of interoperability concepts, utilizing technology wherever possible to aid care delivery, robotics, closed loop medication administration systems, and the internationally recognized Command Centre with tiles dedicated to Risk of Harm and Patient Safety [17]. HRH is an exemplar for digital infrastructure design, earning a LEED Gold Certified facility, and ranked second internationally for energy efficiency in Greening Health Care’s benchmark of over 280 large and urban hospitals across Canada, United States, and Europe. In 2023, through continuous improvement endeavors, HRH opened Schulich Family Medicine Teaching Unit – an academic medicine clinic which provides training for new family physicians. Implementation Overview In 2016, the HRH Senior Management Team committed to adopting the five HRO principles. The HRH Board of Directors set a clear strategic direction for high reliability, prioritizing quality, patient safety and the innovations that serve this agenda. With the direction set, the HRH Senior Management Team began to plan the HRO principles in various strategies through a systematic and transparent approach, such as embedding these principles into the HRH Quality & Safety Framework [18] and the Patient Safety Plan [19]. Additionally, the HRH Quality & Safety Framework served as a logic model, with theoretical integration of multiple safety frameworks including: Hollnagel’s Safety I & Safety II Framework [20], Reason’s Culture of Safety Framework [15], Rasmussen’s Dynamic Model of Errors [21], Healthcare Excellence Canada’s Patient Safety Framework [22], Vincente’s Safety Measurement Framework [23], Donabedian’s Framework for Quality [24], Registered Nurses’ Association of Ontario Best Practice Guideline Framework for Micro- Meso- Macro- Systems [25] and Zhang’s Human Factors/Heuristic Design Principles [26]. This HRH Framework is available on the external website [18]. The Patient Safety Plan [19] then served as the driver diagram to the ultimate goal of safest patient care, thereby reducing preventable harm. Continuing with McDonald’s [10] and Ward’s [11] argument for whole system understanding, leaders need to be cognizant of individuals, teams, processes and their dynamic interconnectedness which impact overall organizational change. Thus, the HRH Senior Management Team resolved not to follow the traditional “reductionist” approach in identifying why things go wrong. By committing not to over-simplify root cause analysis, simultaneously supported a “whole systems” perspective - understanding system complexity in its entirety underpinned planning advantages that leverage mechanisms for whole system change [11,25]. This approach resonated strongly as hospitals have long been recognized as complex socio-technical systems, where multiple departments and services function in continuous and parallel operations but incorporate autonomous clinical decision making both in and outside the point-of-care [20,27, 28]. A central tenet of implementation science is that implementation strategies are most successful when they align with a healthcare systems’ existing culture, infrastructure, and practices 11,29 . Thus various safety initiatives (such as interprofessional systems review and Command Centre Tiles) were planned taking Reason’s Safety Culture and sub-cultures [15] into consideration for planning and rollout. As part of the initial planning, the HRH Senior Management Team began planning our most significant safety initiatives categorized against the HRO principles (see Table 1 ) to determine if there were opportunities to strengthen programming with respect to each of the HRO principles. Table 1. Overarching HRH Programs Initiatives Aligned with High Reliability Organization Drivers (HRO) Specific HRO Considerations HRO Definition HRH Key system/Process Contributors Sensitivity to Operations Heightened awareness of the state of relevant systems and processes. Command Centre – Generation 1 Command Centre – Generation 2 Perinatal Tile, Clinical Deterioration, Risk of Harm Tiles, Senior Care Tile, Best Practice Spotlight Organization Tile Leadership orientation to day-to-day activities Daily safety huddles, compliance reporting to the Board of Directors Digital quality dashboards Preoccupation with Failure View near misses as opportunity to improve versus proof of success. Quality Risk Management patient safety incident reporting system Corporate Patient Safety Committee Adverse Event Reviews (Chart Reviews) – Patient Safety Action Plans Nursing staff competency testing (physical assessment and communication) Best Practice Spotlight Organization Deference to Expertise Value insights from staff and physicians with the most pertinent safety knowledge over those with administrative status. Reinventing Patient Care Councils – Continuous Quality Improvement Councils Studer practices Staff/Physician/Volunteer Engagement Survey Patient Engagement / Patient Family Advisors Interprofessional System Reviews Corporate and Program-specific Patient and Family Advisory Committees Focus groups Resilience Prioritize emergency training and plan for many unlikely but possible system failures. Pandemic Planning / Emergency Preparedness Incident Management Systems Comprehensive staffing plans Nursing Resource Teams / Workforce Forecasting Simulation/Escalation Training Accreditation tracer / audits Actively planning redundancies within the system Emergency drills / mock code red/green/orange/blue Reluctance to Simplify Accept that work is complex, with the potential to fail in new and unexpected way. Interprofessional and Cross Functional System Reviews Human Factors Analysis Integrated Risk Management Failure Mode Effect Analysis Next, additional initiatives were planned and implemented to complete the “whole system safety” planning at HRH (see Supplementary Table S1 in Supplementary Materials). While many initiatives were put into place at HRH, the overarching goal was to achieve the highest level of hospital safety as reported through the Hospital Harm Project. The Hospital Harm Project is a unique partnership between the Canadian Institute for Health Information (CIHI) and Healthcare Excellence Canada, annually reporting the unintended patient safety incidents in acute care hospitals that could have been prevented by complying with evidence-based practices [29]. The annual Hospital Harm report became an organizational focus for HRH and a key report for the HRH Board of Directors. Planning purposefully for long-term change at HRH, all initiatives included in the Supplementary Table S1 have been maintained for a minimum of three years (including patient family advisor board representation as this implementation began in 2023). Ultimately, no initiatives were removed from the list, and all initiatives had control measures planned to ensure triggers would help teams recognize failure of adherence. The purpose of establishing controls within the planning process was to ensure long-term implementation success. Methods Aim The team undertook a study to specifically explore the whole system safety approach at HRH as an HRO. Thus, we translated HRO principles to explore the whole system safety approach at HRH as a high reliability organization to reduce preventable harm within the organization and incorporate Reason's foundational safety culture framework to explore domains that manifest in highly reliable daily operational practices. Case Study A single-organization case study method was used and reported (see Appendix A [ 30 ]) to explore a deeper understanding of HRH and its safety approach. Single-organization studies have been noted as a legitimate means to develop and gain contextualized explanation and understanding of the phenomenon of interest [ 31 ]. Both qualitative analysis (i.e., hospital documentation) and quantitative analysis (using CIHI Hospital Harm results [ 32 ]) were used to provide insights into the relationship between the two frameworks approach for safety, and the overall observed Hospital Harm measures with respect to patient safety outcomes. With respect to reflexivity, the authors (JY, BC) note that wherever possible, biases were acknowledged and an explicit part of discussions involved in coding throughout the document analysis phase. Qualitative Document Analysis and Theoretical Triangulation A document analysis approach used for theoretical triangulation for this single-organization case study [ 33 – 35 ] based on close reading of all relevant publicly available hospital documents and data coding (using pre-set codes as defined with selected frameworks). Both qualitative and quantitative data were collected and used for this study, focus was primarily on publicly available resources to create a complementary and complete big-picture understanding of the improved Hospital Harm results experienced at HRH. For the qualitative phase, HRH-specific public documentation was reviewed using directed (deductive) document analysis. All institutional documents were compared against two separate frameworks relevant for patient safety through high reliability principles and Reason’s safety sub-cultures [ 1 , 15 ]. For the qualitative analysis, we applied deductive document analysis to the data with respect to initiatives using the five HRO principles [ 1 ] ( operational sensitivity, pre-occupation with failure, deference to expertise, commitment to resilience , and reluctance to simplify ) as well as Reason’s five sub-cultures of safety culture [ 15 ] ( Informed Culture, Learning Culture, Flexible Culture, Reporting Culture, Just Culture ). Conduct of the qualitative analysis, relevant internal documents for each of the strategies and initiatives were located and reviewed. The complete analysis of documents comprised of 45 regularly produced reports, 42 procedural documents, 24 policy documents, 22 training documents, 4 legislative requirements, 4 orientation manuals, 3 committee terms of references, 2 regularly conducted surveys, 1 electronic medical record manual, and 1 memorandum of understanding. A full list of documents can be accessed in Supplementary Table S2 . The year that the initiative was implementation was also included (and as Table 4 notes), many initiatives were in place prior to 2015. It is important to note that extracted statements from the documents in fact matched multiple codes in both frameworks. A second coder enlisted to code documents independently to increase trustworthiness of the final codes for analysis. All conflicting codes (less than 5%) were discussed between the two independent coders, using the same definitions for each of the principles and sub-cultures, and all codes were agreed upon through consensus. The results of analyzing the document analysis separately against each framework provided opportunity for theory triangulation interpretation including concepts that overlap and others that may contradict each other. Quantitative Analysis For the quantitative analysis to reflect a whole systems safety approach, we extracted the CIHI hospital harm rates from the CIHI portal, which include HRH data, as well as benchmarked provincial and national hospital rates, specifically, Ontario hospital rates and Canada’s hospital rates. These hospital harm rates are reported as data extracted from various acute care health records (using primarily the CIHI Discharge Abstract Database) and initially reported as crude rates where the numerator is as the total number of patients experiencing harm during their admission, divided by total number of patients discharged per fiscal year [ 32 ]. Important to note, CIHI definition for harm is not limited one singular category, but is in fact based on 31 different types of preventable harms, broken down into four major categories (Health-care / Medication-Associated Conditions such as pressure ulcers, medication errors; Health-Care–Associated Infections (such as hospital-acquired infections); Procedure-Associated Conditions (such as complications from surgery, like bleeding); and Patient Accidents (such as falls in hospital) 31 . The HRH harm rates for each of the four CIHI harm categories were then analyzed respectively; chi-squared (C 2 ) test of independence was performed using the Canada-wide rates as the expected frequency and compared to the observed frequency. HRH rates for which the resulting p-value from the respective C 2 test was greater than 0.05 was considered comparable to Canada-wide rates, whereas any HRH rates where with the resulting p-values was below 0.05 indicated a significant difference between HRH rates and Canada-wide rates. Results As noted, there are 56 initiatives that were implemented at HRH. The rest were implemented over the period of 2016 to 2025, with the largest group of new initiatives started and sustained since 2016. Most initiatives that were implemented post-2015 are based on the concept of leading indicators (i.e. proactive approach to safety) rather than lagging indicators (i.e. reactive organizational responses to safety). Drawing from the results of the deductive coding, we observe a high level of agreement of manifestation of HRO Principles and safety sub-cultures. The HRH initiatives listed in Supplementary Table S1 are assumed to contribute to the significant reduction of patient safety incidents. Emphasis on flexible culture highlights the agility and adaptability that is required for HROs. Overall, 56 different strategies were implemented at HRH from the period of 2015 to 2025, starting at the Wilson site ( Supplementary Table S1 ). In total, the strategies ensured a comprehensive whole-system approach to safety, highlighting the multiple HRO principles, and domains of safety culture as defined by Reason [ 15 ]. For example, the planning and implementation of the Command Centre Generation 1 tiles (patient flow) support the HRO principles of sensitivity to operations, pre-occupation with failure, resilience , and reluctance to simplify ( Supplementary Table S1 , strategy #1). These tiles support a flexible culture where teams are in continuous reflection of patient flow, proactively and in-the-moment to prioritize and re-allocate resources that support maximizing hospital capacity. To further illustrate a whole system approach, strategic nursing workforce planning ( Supplementary Table S1 , strategy #20), is a major strategy for committing to and building organizational resilience through proactive staffing plans that ensure productive patient care delivery despite disruptions; however this strategy is functionally managed through the principle of sensitivity to operations, pre-occupation with failure, deference to expertise, resilience, and reluctance to simplify as individual units must report and manage staffing vulnerabilities, in addition to forecasting these needs [ 36 ]. As such, a flexible culture is created, affording the ability to prioritize and re-allocate staffing as required to ensure safe patient care delivery. Figure 3 provides an overview of total patients harmed as a crude ratio calculated against total discharged patients in each fiscal year between HRH and includes an aggregate harm score for all Ontario hospitals, as well as an aggregate harm score for all hospitals across Canada [ 32 ]. In 2014/15 the hospital harm rate for HRH was comparable to the Ontario and Canada aggregate scores, however there is a noticeable downward trend for HRH over the 2015/16 to 2018/19. The lowest rates of harm experienced by HRH were sustained for seven consecutive years. Table 2 provides the comparison of HRH rates against the Canadian hospital harm rates. In 2014/15, only medication errors at HRH were noted to be significantly lower than the Canadian hospital rate, which can be credited to the closed-loop medication system that was already in place at the time. By 2017/18, HRH hospital harm rates in all four categories of harm were significantly lower than the Canadian hospital rate. Table 2 Chi-squared (C 2 ) Test of Independence between HRH Rates of Harm versus the Canada-wide Rates of Harm per fiscal year HRH Medication/ Condition-Associated Errors HRH Infection-Associated Errors HRH Patient Accidents HRH Procedure-Associated Errors Canada-wide Hospital Medication/ Conditions-Associated Errors Canada- wide Hospital Infection-Associated Errors Canada- wide Hospital Patient Accidents Canada-wide Hospital Procedure-Associated Errors 2014/15 2.65 (p < 0.05) 2.30 (p > 0.05) 0.24 (p > 0.05) 1.34 (p > 0.05) 2.65 2.09 0.21 1.33 2015/16 3.20 (p < 0.05) 1.80 (p < 0.05) 0.20 (p > 0.05) 1.10 (p < 0.05) 2.72 2.06 0.19 1.37 2016/17 1.90 (p < 0.05) 1.00 (p < 0.05) 0.20 (p > 0.05) 0.80 (p < 0.05) 2.79 2.00 0.20 1.37 2017/18 1.80 (p < 0.05) 1.00 (p < 0.05) 0.10 (p < 0.05) 0.90 (p < 0.05) 2.81 1.96 0.21 1.35 2018 /19 1.10 (p < 0.05) 0.60 (p < 0.05) 0.10 (p < 0.05) 0.70 (p < 0.05) 2.83 1.91 0.22 1.33 2019/20 1.00 (p < 0.05) 0.50 (p < 0.05) 0.10 (p < 0.05) 0.80 (p < 0.05) 2.93 1.91 0.23 1.34 2020/21 1.20 (p < 0.05) 0.80 (p < 0.05) 0.10 (p < 0.05) 0.70 (p < 0.05) 3.27 2.09 0.26 1.43 2021/22 1.00 (p < 0.05) 0.60 (p < 0.05) 0.10 (p < 0.05) 0.70 (p < 0.05) 3.35 2.20 0.26 1.34 2022/23 1.10 (p < 0.05) 0.90 (p < 0.05) 0.10 (p < 0.05) 0.90 (p < 0.05) 3.37 2.26 0.27 1.33 2023/24 1.00 (p < 0.05) 0.70 (p < 0.05) 0.10 (p < 0.05) 0.70 (p < 0.05) 3.40 2.19 0.26 1.30 2024/25 1.00 (p < 0.05) 0.80 (p < 0.05) 0.10 (p < 0.05) 0.70 (p < 0.05) 3.36 2.17 0.26 1.30 Footnote: The table provides a comparison of the year-over-year hospital harm rates broken down by the four major categories of hospital harm. The statistical significance using chi-squared independence test between the HRH rates and Canada-wide hospital rates between the larger discharged patients against those that were discharged from HRH per each fiscal year. Statistically significant results have been bolded. At the outset of the document analysis, the number of initiatives were counted per implementation year. Of note, 23 safety initiatives were already in place during 2015 – the largest set of new patient safety initiatives were then implemented in 2016, followed by the next largest set of safety initiatives in 2017. The last initiative which began in 2025 was the induction of a formal patient and family advisor as a board member of the hospital’s Board Quality Assurance Committee – from the documents, however the work to bring a representative to the board committee began in 2023, and a Terms of Reference was established for the patient and family advisor to remain. Table 3 Number of Quality and Patient Safety Initiatives Implemented Per Year at HRH Year Number of New Quality & Patient Safety Initiatives at HRH Total Number of Quality and Patient Safety Initiatives at HRH (percentage of all initiatives) 2015 0 23 (41.1%) 2016 10 33 (58.9%) 2017 8 41 (73.2%) 2018 4 45 (80.4%) 2019 2 47 (83.9%) 2020 5 52 (92.9%) 2021 3 55 (98.2%) 2022 0 55 (98.2%) 2023 0 55 (98.2%) 2024 0 55 (98.2%) 2025 1 56 (100%) Despite the many initiatives that were in place at the start of the 2015 timeframe (23 initiatives listed as per Table 3 ), a large injection of new initiatives begun in 2016 (10 initiatives), and 2017 (8 initiatives). Of note, most initiatives that were implemented post-2015 are based on the concept of leading indicators (i.e. proactive approach to safety) rather than lagging indicators (i.e. reactive organizational responses to safety). Drawing from the results of the deductive coding, we observed a high level of agreement of manifestation of HRO Principles and safety sub-cultures. The HRH initiatives listed in Table 2 are assumed to contribute to the significant reduction of patient safety incidents. Table 4 provides an overview of safety initiatives against the five HRO principles and Reason’s five sub-cultures for safety. It became quickly apparent that many of the safety initiatives that were implemented at HRH in fact crossed multiple principles as well as multiple sub-cultures. The high level of alignment supported the notion of synergy that could occur between the two frameworks in this single-organization case study. Table 4 Comparison of the Number of HRH Quality and Patient Safety Initiatives which aligned with Each of the HRO Principles and Reason’s five sub-cultures of Safety Culture HRO Principle Number of Quality and Patient Safety Initiatives at HRH Proportion of Alignment Preoccupation with Failure 50 89.3% Sensitivity to Operations 43 76.8% Reluctance to Simplify 38 67.9% Commitment to Resilience 36 64.3% Deference to Expertise 34 60.7% Reason’s Sub-Culture Description Number of Quality and Patient Safety Initiatives at HRH Proportion of Alignment Learning Culture 46 82.1% Informed Culture 45 80.4% Flexible Culture 38 67.9% Reporting Culture 36 64.3% Just Culture 8 14.2% Discussion This single-organization case study examined institutional documents against two separate frameworks relevant for patient safety through high reliability principles and Reason’s safety sub-cultures. The alignment between both frameworks provided meaningful opportunity to bring together the relevancy of two separate frameworks. Professional organizations such as the Registered Nurses’ Association of Ontario have also observed beneficial synergies in bringing together two separate frameworks (i.e. Knowledge-To-Action Framework and Social Movement Action Framework) as a successful way for healthcare organizations to support accelerated implementation of best practice guidelines [ 37 ]. We identified 56 different strategies employed by the hospital, which ultimately contribute to whole system safety approach at HRH. The majority of strategies exhibit multiple HRO principles and the safety sub-cultures, which in turn improve delivery of reliable care. The study results suggests that the HRO principles clearly support the behavioral and operational patterns, which are embedded into policies, procedures, reports and education at HRH. By way of implementing many safety initiatives that reinforced constructs from both frameworks, the organization’s contextual, social-technical and process components are likely to have in turn supported a mature safety culture – and we suggest that a mature safety culture has been critical to support and sustain the low hospital harm rates over seven years. A large introduction of 10 initiatives occurred in 2016, followed by another 8 initiatives in 2017. These included beginning the reporting of safety huddles to the board of directors, interprofessional system reviews, nursing workforce planning and forecasting, simulations-based training, clinical practice leader development (including quality improvement and patient safety sciences), scholarly poster development, unit-specific quality dashboards, deep dive education sessions for the Board Quality Assurance Committee, creating a Quality & Safety Framework as well as creating a Patient Safety Plan. Of note, safety huddles, workforce planning, simulations-based training, leader development, staff rounding, patient rounding, surgical safety checklists, and patient safety plan-development are meaningful with respect to leading indicators (proactively planning) for safety. Overall Contributors to HRH as a High Reliability Organization and Mature Safety Culture Drawing from the results of the deductive coding, we observed a high level of agreement of manifestation of HRO Principles and safety sub-cultures of the HRH initiatives (Table 2 ). Not only has there been a large number of safety initiatives put in place that contribute to whole safety system approach, but many of these initiatives are proactive in nature (e.g. surgical safety checklists, safety huddles to flag to management future safety risks) rather than reactive in nature (e.g. incident reporting). With increasing the number of proactive safety initiatives, this approach supports both individuals and systems in pre-emptively preventing incidents but may also have significantly improved the maturity of the organization’s safety culture with respect to paying attention to both what went wrong and what could go wrong. Convergence between Frameworks Firstly, based on the cross-examination of the institutional documents against both frameworks, the highest level of overlap was observed between pre-occupation with failure (HRO principle) , with learning culture (Reason) , both of these concepts place critical emphasis on examining mistakes, near misses, and potentially recognize signals to drive continuous quality improvement. Pre-occupation with failure tends to focus on patients, staff and leaders to constantly surveillance for difficult-to-detect signals that may underpin a larger concern. A learning culture will concurrently emphasize a general level of “unease” and opportunity for learning at all staff levels. Error reporting (for both patient-related or process-related issues), adverse events, and near misses have long been recognized as the greatest opportunities for organizational learning [ 37 , 38 ]. While harm or errors may have occurred, a learning culture will support opportunities to disseminate learnings not only as a result of an error, but also to prevent one of a similar nature from occurring in the future. One such opportunity for learning is interprofessional, cross-functional system reviews involve clinicians, non-clinicians, leaders and patient representatives in a deep-dive of the incident in question. What is unique at HRH are these actions for system reviews. While there is very little published in the literature with regards to interprofessional safety reviews, in the ICU, a standardized method (the Orion method inspired by the aeronautic industry) has been employed using long-term engagement with the direct care team [ 40 ]. Following this example, the HRH system review approach undertook a presentation-style chart review with all clinicians and non-clinicians (e.g. support service staff) who were actively involved in a safety incident to share their insights and perspectives that may have influenced decision-making or suggest process or policy-improvement opportunities that could prevent a similar incident from occurring in the future. An action plan was developed through consensus, and report back to all teams once process improvements are completed. This approach places a greater emphasis on process improvement based on a hierarchy of effectiveness [ 41 ] rather than a fallible individual (e.g. human factors perspective) and has since opened dialogue for setting up systems for safety, no matter how small the concern may be. A second illustrative example of an initiative that aligns pre-occupation with failure and learning culture is the patient-simulated physical assessment test, which all new nursing hires are expected to pass. This assessment test supports general recognition of missing early warning signs of deterioration [ 16 , 42 , 43 ], as well as practicing structured communication leading to failure to rescue [ 44 ]. Despite the popularity of early warning systems-based research, most studies did not provide details to inform real-world adoption [ 45 ]. Newly hired staff are provided with rubrics and simulation scenarios to practice recognizing a clinical concern (as a combination of correct assessment technique and interpretation) and communicating the findings to another professional in a Situation-Background-Assessment-Recommendation (SBAR) format. Individuals can undertake the physical assessment test three times (including multiple practice shifts in between each test), as staff may have different prior work and education experiences prior to their hire at HRH, however the expectations for identifying early deterioration and accurately communicating the concerns appropriately are clear. The next greatest level of overlap from this analysis was operational sensitivity (HRO principle) and an Informed sub-culture (Reason). What this alignment suggests is that both constructs are jointly reliant and functional based on generating frontline reporting of information and building increased situational awareness. Without surprise, operational sensitivity and informed sub-culture reinforce the expectation of staff and leaders to remain as connected to operational details, no matter how miniscule the detail may be. When emphasis is placed on accurate, timely knowledge of frontline conditions through open communication, this mechanism in fact supports developing respect for knowledge authority rather than healthcare teams relying functionally on positional authority only [ 46 ]. A key example increasing situational awareness and acting on such safety information that is accomplished through the Command Centre; for example, vital sign changes over time and are captured electronically in the EMR, and early warning signs of deterioration are signaled to staff and leaders alike, by alerts that are triggered in Command Centre Generation 2 Tiles [ 17 ]. As another illustrative example for operational sensitivity (HRO principle) and informed sub-culture (Reason) are mandated daily safety huddles – the frequency of the safety huddles is reported to the hospital board of directors as a control measure, but in fact the quality of the safety concerns raised in daily safety huddles are then addressed proactively. Daily organizational safety huddles have long been recognized as an important “pause” for situation awareness [ 39 , 47 ]. The operational sensitivity and informed sub-culture are recognized to improve problem-solving and optimal patient outcomes [ 48 ]. Of note, both of these examples are leading indicators for safety (i.e. proactive in identifying safety issues) – they are operationalized to include safety protocol actions in addition to just identifying safety risks. Divergence between Frameworks Interestingly, the one principle between both frameworks that appears to have been realized the least between all HRO principles and safety sub-cultures at HRH is Just Culture (16%). While this disparity may be interpreted as far less initiatives supporting Just Culture at HRH, most of the published literature with regards to Just Culture is largely theoretical in nature [ 38 ]. Murray [ 38 ] also notes that many organizations have noted challenges in interpreting, let alone implementing Just Culture. Internal discussions, and hundreds of site visits from international hospital leaders over the years have highlighted the complex nature of blame in the context of healthcare errors [ 49 ]. Within HRH, leaders have taken the stance that Just Culture is best positioned as assigning the appropriate level of culpability between individuals and the system they work in through an incident decision tree. For example, organizations should recognize that while clinicians’ endeavor to document their assessments and findings accurately as possible, an electronic medical record screen may be missing fields that are important to prompt key pieces of information. As such, organizations should work towards supporting employees making the right decisions, as well as using all opportunities to make process improvements systematically (e.g. document optimization). Though this study explored two frameworks to help gain a deeper understanding of the whole system safety experience at HRH, we recognize the most significant limitation is with regards to the generalizability of the results. Our interpretations assist with nuanced understanding of how HRO principles and Reason’s Safety Culture Framework are synergistic, supportive frameworks for a single organization. However, a clear opportunity has been identified for further research, which aligns with the gap in current literature. Conclusion HRH, a large and complex hospital setting, has demonstrated that such an organization can achieve a significant reduction in preventable harm, and a hospital harm rate that has been sustained for multiple years as a testimony that it is possible to focus relentlessly on high reliability and safe patient care. These outcomes diverge from the typical shallow engagement with high reliability principles into sustained interconnected nature between persons delivering and overseeing care, safety process and practice improvements within an organization. Overall, directed document analysis against two synergistic frameworks has been insightful – the strategies listed that are used at HRH support positive implications and suggestions for policy, practice and future research directions for other healthcare settings. Especially with alignments discovered between pre-occupation with failure and learning culture , and operational sensitivity and informed sub-culture , these alignments speak to organizational cultures which choose to pay attention to small signals that may have large returns in safety for the future. Other organizations may also realize that with a chosen focus on implementing high reliability principles, they may inherently also be improving safety culture maturity as described by Reason’s Safety Culture Framework. While further research would be beneficial to further understand the implementation and specific impact of both frameworks at play, specific additional efforts should be focused on how just sub-culture was successfully implemented and its role in promoting and sustaining a culture of safety [ 38 ]. Declarations Ethics Review The work undertaken in this organization was part of ongoing/continuous quality improvement using publicly available data, and no study participants were required. Institutional Review Board approval was not required in accordance to the hospital’s research determination policy, as well as the Tri-Council Policy Statement 2 (TCPS-2, 2022) Protocol. Nonetheless, an A pRoject Ethics Community Consensus Initiative (ARECCI) screening was completed, resulting in a score of 0. Consent for publication: Not applicable. Competing Interests: All authors have declared no conflict of interest. Author Details: 1 Humber River Health, Toronto, Canada 2 Queen’s University, Kingston, Canada 3 University of Toronto, Toronto, Canada Funding: This study received no external funding Author Contribution J.Y. was responsible for design of the study, data processing. J.Y. and A.Z. were responsible for the analysis of the results and writing the manuscript. B.E.C. revised this manuscript. Acknowledgement The authors would like to acknowledge the overwhelming support of the Board of Directors, Senior Management Team, all clinical and non-clinical teams, clinical practice leaders, and volunteers. Data Availability Documents used for this analysis are publicly available, and can be made available upon request to the corresponding author. References Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed. San Francisco: Jossey-Bass; 2007. Myers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf. 2022;31(12):845–8. doi.org/10.1136/bmjqs-2021-014141 . Cantu J, Tolk J, Fritts S, Gharehyakheh A. High Reliability Organization (HRO) systematic literature review: Discovery of culture as a foundational hallmark. J Contingencies Crisis Manag. 2020;28(4):399–410. doi.org/10.1111/1468-5973.12293 . Cantu J, Tolk J, Fritts S, Gharehyakheh A. Interventions and measurements of highly reliable/resilient organization implementations: A literature review. Appl Ergon. 2021;90. doi.org/10.1016/j.apergo.2020.103241 . Cincinnati Children’s. Becoming a high reliability organization. https://www.cincinnatichildrens.org/research/divisions/j/anderson-center/safety/methodology/high-reliability Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91:459–90. doi.org/10.1111/1468-0009.12023 . World Health Organization. Global patient safety action plan 2021–2030. 2021. https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan Rotteau L, Goldman J, Shojania KG, et al. Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. BMJ Qual Saf. 2022;31(12):867–77. 10.1136/bmjqs-2021-013938 . Goldstein DH, Nyce JM, Van Den Kerkhof EG. Safety perceptions of health care leaders in 2 Canadian academic acute care centers. J Patient Saf. 2017;13(2):62–8. McDonald N, McKenna L, Vining R, Doyle B, Liang J, Ward M, Ulfvengren P, Geary U, Guilfoyle J, Shuhaibar A. Evaluation of Access-Risk-Knowledge (ARK) Platform for Governance of Risk and Change in Complex Socio-Technical Systems. Int J Environ Res Public Health. 2021;18:12572. Ward ME, Daly A, McNamara M, Garvey S, Teeling SP. A Case Study of a Whole System Approach to Improvement in an Acute Hospital Setting. Int J Environ Res Public Health. 2022;19(3):1246. Ford JL. Revisiting high-reliability organizing: obstacles to safety and resilience. Corp Commun. 2018;23(2):197–211. doi.org/10.1108/CCIJ-04-2017-0034 . Veazie S, Peterson K, Bourne D. Evidence brief: Implementation of high reliability organization principles. Washington, DC: U.S. Department of Veterans Affairs, Health Services Research and Development Service ; 2019. https://www.ncbi.nlm.nih.gov/books/NBK542883/ Simpson D, Hamilton S, McSherry R, McIntosh R. Measuring and Assessing Healthcare Organisational Culture in England’s National Health Service: A Snapshot of Current Tools and Tool Use. Healthcare 2019, 7, 127. Reason J. Achieving a safe culture: Theory and practice. Work stress. 1998;12(3):293–306. Levett-Jones T, Hoffman K, Dempsey J, Jeong SYS, Noble D, Norton CA, et al. The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Educ Today. 2010;30(6):515–20. doi.org/10.1016/j.nedt.2009.10.020 . Collins BE. Reducing Hospital Harm: Establishing a Command Centre to Foster Situational Awareness. Healthc Q. 2022;25(2):75–81. 10.12927/hcq.2022.26885 . Humber River Health. Quality Safety Framework. https://www.hrh.ca/wp-content/uploads/2023/01/Quality-and-Safety-Framework.pdf Humber River Health. Patient Safety Plan. https://www.hrh.ca/wp-content/uploads/2025/10/Patient-Safety-Plan-FY2025-26.pdf Hollnagel E. Safety-i and safety-ii: the past and future of safety management. First edition. Boca Raton, FL: CRC Press, an imprint of Taylor and Francis; 2014. Rasmussen J. Risk management in a dynamic society: a modelling problem. Saf Sci. 1997;27(2):183–213. Healthcare Excellence Canada. The Canadian Quality & Patient Safety Framework for Health Services. https://www.healthcareexcellence.ca/media/e3dkkwos/cpsi-10001-cqps-framework-english_fa_online-final-ua.pdf Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316(7138):1154–7. Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Q . 1966;44(3)(suppl):166-206. Reprinted in Milbank Q . 2005;83(4):691‐729. Grinspun D, Bajnok I. Registered Nurses’ Association of Ontario issuing body. Sigma Theta Tau International issuing body. Transforming nursing through knowledge: best practices for guideline development, implementation science, and evaluation. Indianapolis, IN: Sigma Theta Tau International; 2018. Zhang J, Johnson TR, Patel VL, Paige DL, Kubose T. Using usability heuristics to evaluate patient safety of medical devices. J Biomed Inform. 2003;36(1):23–30. doi.org/10.1016/S1532-0464(03)00060-1 . Patriarca R, Di Gravio G, Woltjer R, Costantino F, Praetorius G, Ferreira P et al. Framing the FRAM: A literature review on the functional resonance analysis method. Saf Sci. 2020;129. Wachter RM. Understanding patient safety [Internet]. 2nd ed. New York, N.Y: McGraw-Hill Education LLC.,; 2012. Aarons G, Hurlburt M, Horwitz S. Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors. Adm Ment Health. 2011;38:4–23. Runeson P, Höst M. Guidelines for conducting and reporting case study research in software engineering. Empir Softw engineering: Int J. 2009;14(2):131–64. Welch C, Paavilainen-Mäntymäki E, Piekkari R, Plakoyiannaki E. Reconciling theory and context: How the case study can set a new agenda for international business research. J Int Bus Stud. 2022;53(1):4–26. Canadian Institute for Health Information. Hospital Harm Results, 2014–2015 to 2024–2025. Ottawa, ON: CIHI; 2025. Bowen GA. Document Analysis as a Qualitative Research Method. Qualitative Res J. 2009;9(2):27–40. doi.org/10.3316/QRJ0902027 . Taylor M, Garner P, Oliver S, Desmond N. Use of qualitative research in World Health Organisation guidelines: a document analysis. Health Res Policy Syst . 2024;22(1):44. Published 2024 Apr 4. 10.1186/s12961-024-01120-y Arias Valencia MM. Principles, Scope, and Limitations of the Methodological Triangulation. Investigación y educación en enfermería. 2022;40(2). Yoon J, Hutchinson D, Marville-Williams C, et al. Case Study: The Impact of Nursing Professional Practice during the COVID-19 Pandemic at a Large Community Hospital in Canada. Nurs Leadersh (Tor Ont). 2022;35(3):48–65. 10.12927/cjnl.2022.27003 . Registered Nurses’ Association of Ontario. Two Complementary Frameworks. https://rnao.ca/bpg/leading-change-toolkit/two-complementary-frameworks-bak Murray JS, Lee J, Larson S, Range A, Scott D, Clifford J. Requirements for implementing a ‘just culture’ within healthcare organisations: an integrative review. BMJ Open Qual. 2023;12(2):e002237. doi.org/10.1136/bmjoq-2022-002237 . Woodier N, Burnett C, Moppett I. The Value of Learning From Near Misses to Improve Patient Safety: A Scoping Review. J Patient Saf. 2023;19(1):42–7. doi.org/10.1097/PTS.0000000000001078 . Chapuis C, Chanoine S, Colombet L, Calvino-Gunther S, Tournegros C, Terzi N, et al. Interprofessional safety reporting and review of adverse events and medication errors in critical care. Ther Clin Risk Manag. 2019;15:549–5. doi.org/10.2147/TCRM.S188185 . Cafazzo JA, St-Cyr O. From Discovery to Design: The Evolution of Human Factors in Healthcare. Healthcare Quarterly (Toronto, Ont). 2012;15(SP1):24–9. doi.org/10.12927/hcq.2012.22845 Chua WL, Legido-Quigley H, Ng PY, McKenna L, Hassan NB, Liaw SY. Seeing the whole picture in enrolled and registered nurses’ experiences in recognizing clinical deterioration in general ward patients: A qualitative study. Int J Nurs Stud. 2019;95:56–64. doi.org/10.1016/j.ijnurstu.2019.04.012 . McGhee TL, Weaver P, Solo S, Hobbs M. Vital signs reassessment frequency recommendation. Nurs Manag. 2016;47(9):11–2. doi.org/10.1097/01.NUMA.0000491132.98848.22 . Ghaferi AA, Dimick JB. Importance of teamwork, communication and culture on failure-to-rescue in the elderly. Br J Surg. 2016;103(2):e47–51. doi.org/10.1002/bjs.10031 . Esmaeilzadeh S, Lane CM, Gerberi DJ, Wakeam E, Pickering BW, Herasevich V, et al. Improving In-Hospital Patient Rescue: What Are Studies on Early Warning Scores Missing? A Scoping Review. Crit Care Explorations. 2022;4(2):e0644. doi.org/10.1097/CCE.0000000000000644 . Burkoski V, Yoon J. Continuous quality improvement: a shared governance model that maximizes agent-specific knowledge. Nurs Leadersh (Tor Ont) . 2013;26 Spec No 2013:7–16. 10.12927/cjnl.2013.23363 Fencl JL, Willoughby C. Daily Organizational Safety Huddles: An Important Pause for Situational Awareness. AORN J. 2019;109(1):111–8. doi.org/10.1002/aorn.12571 . Burr KL, Stump AA, Bladen RC, O’Brien PR, Lemon BJ, Tearl DK, et al. Twice-Daily Huddles Improves Collaborative Problem Solving in the Respiratory Care Department. Respir Care. 2021;66(5):822–8. doi.org/10.4187/respcare.07717 . Collins ME, Block SD, Arnold RM, Christakis NA. On the prospects for a blame-free medical culture. Social Science & Medicine (1982). 2009;69(9):1287–90. doi.org/10.1016/j.socscimed.2009.08.033 Additional Declarations No competing interests reported. Supplementary Files 20260205SupplementaryTablesS1S2.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 08 Apr, 2026 Reviewers agreed at journal 12 Mar, 2026 Reviewers invited by journal 20 Feb, 2026 Editor invited by journal 10 Feb, 2026 Editor assigned by journal 10 Feb, 2026 Submission checks completed at journal 10 Feb, 2026 First submitted to journal 05 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8800008\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":596272717,\"identity\":\"e65efb0a-c805-4ef3-babc-89fa00e9f33e\",\"order_by\":0,\"name\":\"Jennifer Yoon\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAlElEQVRIiWNgGAWjYBACxgYQWXGAwYBELWdI0QLR10aKFuYZyQcfF867k2/OwPzwA3EWzEhLNp657ZnlzgY2YwkiteSYSfNuO2xgcICHgRQtc8BamH+QoKUBrIWNSFt6niUb8xwDajnMZmZBlBbDdmCI8dQAtRxvfnyDOC0TEqAsZqLUA4E8/wFilY6CUTAKRsGIBQC4Ly3hsIIacwAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Humber River Health\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Jennifer\",\"middleName\":\"\",\"lastName\":\"Yoon\",\"suffix\":\"\"},{\"id\":596272720,\"identity\":\"26ea4f8d-3772-489e-bd01-c13541d45390\",\"order_by\":1,\"name\":\"Barbara E. 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The field of high reliability organizations (HROs) emerged as Weick and Sutcliffe [1] examined aeronautic and nuclear engineering industries in how they manage daily business despite the potential for catastrophic operational outcomes [1,2]. Five principles emerged that support HRO operations [1,3-6] (\\u003cstrong\\u003eFigure 1\\u003c/strong\\u003e): sensitivity to operations (maintaining high awareness of changing operational conditions), preoccupation with failure (maintaining heightened sense of vigilance of possible failure), reluctance to simplify (resisting oversimplification of work processes to gain deeper understanding of problems), commitment to resilience (fundamentally understanding the frequent and unpredictable nature of system failures), and deference to expertise (appreciating the persons closest to an incident are the most knowledgeable about it).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOver a decade ago, there was a push toward HRO principles in U.S. health care organizations [5]. These principles have led to an expansion of HRO research, particularly in health care settings [3,6]. More recently, the World Health Organization (WHO) developed a Global Patient Safety Action Plan 2021-2030, to support improving patient safety initiatives, highlighting the importance of incorporating high-reliability health systems principles, central to the second strategic objective [7]. In Canada, there is a paucity of research in how HRO principles align with health care organization safety climate, including understanding the principles themselves among those responsible for providing safe patient care [8.9]. Furthermore, the application of these principles are often isolated in action without a strong theoretical foundation [1]. \\u0026nbsp;McDonald [10] and Ward [11] argue whole system understanding including individuals, teams, processes, and their dynamic interconnectedness is critical for impacting system-system level change. Hence, the importance of an interdisciplinary academic-healthcare partnership to address complex systems problems is needed, such as the collaboration of healthcare leaders and scholars to enact HRO principles. \\u0026nbsp;In this paper, we translate HRO principles in a specific Canadian healthcare organization to reduce preventable harm within the organization. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFoundational Framework: Reason\\u0026rsquo;s Safety Culture and Sub-Cultures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eHealthcare organizations that apply high reliability principles must also carefully consider culture as an operational target alongside HRO principles [3,4]. In fact, the concept of culture has also been referred to as the sixth hallmark of HROs (i.e. organizational mindfulness), as it has been argued as the mechanism to synergistically enable the five original HRO principles [1,12,13]. Since recent discussion of organizational culture has been raised as critical component of high reliability, founded on safety culture theory, Reason\\u0026rsquo;s Safety Culture Framework provides a foundation to examine the underlying cultural components (sub-cultures) that support a mature safety culture [14,15].\\u003c/p\\u003e\\n\\u003cp\\u003eReason\\u0026rsquo;s Safety Culture Framework encompasses five distinct components (i.e., sub-culture contributors) that collectively shape organizational safety culture. Recognized as a highly influential model, Reason\\u0026rsquo;s framework provides organizations with a focus on systems thinking, with its approach to error analysis through the lens of human factors, and its commitment to fostering organizational learning [15]. According to Reason, the five components of organizational safety culture are required to achieve a high reliability culture through the following sub-cultures (\\u003cstrong\\u003eFigure 2\\u003c/strong\\u003e): informed culture, reporting culture, just culture, flexible culture and learning culture [15]. The knowledge, skills, attitudes, language and coordinating mechanisms inherent in teamwork, and respective culture affords team members the flexibility to operate but also manage the complexity of care from experience [16].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSetting the Context:\\u003c/strong\\u003e\\u003cstrong\\u003e\\u0026nbsp;Humber River Health (HRH)\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn 2015, a Canadian hospital HRH opened its state-of-the art, fully digital hospital in Toronto \\u0026ndash; a North American first, encompassing remarkable hospital design guided by the principles of \\u003cem\\u003elean, green and digital.\\u0026nbsp;\\u003c/em\\u003eServicing an equity-deserving population of more than 850,000 community members. \\u0026nbsp;The digital hospital site is a 1.8 million square-foot acute care facility that brought together patients and staff from two older hospital sites, of which have been converted into Reactivation Care Centres (i.e., where patients who no longer require acute care but awaiting appropriate care facility). Innovations at the new hospital site include the use of interoperability concepts, utilizing technology wherever possible to aid care delivery, robotics, closed loop medication administration systems, and the internationally recognized Command Centre with tiles dedicated to Risk of Harm and Patient Safety [17]. HRH is an exemplar for digital infrastructure design, earning a LEED Gold Certified facility, and ranked second internationally for energy efficiency in Greening Health Care\\u0026rsquo;s benchmark of over 280 large and urban hospitals across Canada, United States, and Europe. In 2023, through continuous improvement endeavors, HRH opened Schulich Family Medicine Teaching Unit \\u0026ndash; an academic medicine clinic which provides training for new family physicians.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eImplementation Overview\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn 2016, the HRH Senior Management Team committed to adopting the five HRO principles. The HRH Board of Directors set a clear strategic direction for high reliability, prioritizing quality, patient safety and the innovations that serve this agenda. With the direction set, the HRH Senior Management Team began to plan the HRO principles in various strategies through a systematic and transparent approach, such as embedding these principles into the HRH Quality \\u0026amp; Safety Framework [18] and the Patient Safety Plan [19]. Additionally, the HRH Quality \\u0026amp; Safety Framework served as a logic model, with theoretical integration of multiple safety frameworks including: Hollnagel\\u0026rsquo;s Safety I \\u0026amp; Safety II Framework [20], Reason\\u0026rsquo;s Culture of Safety Framework [15], Rasmussen\\u0026rsquo;s Dynamic Model of Errors [21], Healthcare Excellence Canada\\u0026rsquo;s Patient Safety Framework [22], Vincente\\u0026rsquo;s Safety Measurement Framework [23], Donabedian\\u0026rsquo;s Framework for Quality [24], Registered Nurses\\u0026rsquo; Association of Ontario Best Practice Guideline Framework for Micro- Meso- Macro- Systems [25] and Zhang\\u0026rsquo;s Human Factors/Heuristic Design Principles [26]. This HRH Framework is available on the external website [18]. The Patient Safety Plan [19] then served as the driver diagram to the ultimate goal of safest patient care, thereby reducing preventable harm.\\u003c/p\\u003e\\n\\u003cp\\u003eContinuing with McDonald\\u0026rsquo;s [10] and Ward\\u0026rsquo;s [11] argument for whole system understanding, leaders need to be cognizant of individuals, teams, processes and their dynamic interconnectedness which impact overall organizational change. Thus, the HRH Senior Management Team resolved not to follow the traditional \\u0026ldquo;reductionist\\u0026rdquo; approach in identifying why \\u0026nbsp; things go wrong. By committing not to over-simplify root cause analysis, simultaneously supported a \\u0026ldquo;whole systems\\u0026rdquo; perspective - understanding system complexity in its entirety underpinned planning advantages that leverage mechanisms for whole system change [11,25]. This approach resonated strongly as hospitals have long been recognized as complex socio-technical systems, where multiple departments and services function in continuous and parallel operations but incorporate autonomous clinical decision making both in and outside the point-of-care [20,27, 28].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eA central tenet of implementation science is that implementation strategies are most successful when they align with a healthcare systems\\u0026rsquo; existing culture, infrastructure, and practices\\u003csup\\u003e11,29\\u003c/sup\\u003e. Thus various safety initiatives (such as interprofessional systems review and Command Centre Tiles) were planned taking Reason\\u0026rsquo;s Safety Culture and sub-cultures [15] into consideration for planning and rollout. As part of the initial planning, the HRH Senior Management Team began planning our most significant safety initiatives categorized against the HRO principles (see \\u003cstrong\\u003eTable 1\\u003c/strong\\u003e) to determine if there were opportunities to strengthen programming with respect to each of the HRO principles.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1.\\u003c/strong\\u003e \\u003cstrong\\u003eOverarching HRH Programs Initiatives Aligned with High Reliability Organization Drivers (HRO)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"636\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSpecific HRO Considerations\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eHRO Definition\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eHRH Key system/Process Contributors\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSensitivity to Operations\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eHeightened awareness of the state of relevant systems and processes.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eCommand Centre \\u0026ndash; Generation 1\\u003c/p\\u003e\\n \\u003cp\\u003eCommand Centre \\u0026ndash; Generation 2\\u003c/p\\u003e\\n \\u003cp\\u003ePerinatal Tile, Clinical Deterioration, Risk of Harm Tiles, Senior Care Tile, Best Practice Spotlight Organization Tile\\u003c/p\\u003e\\n \\u003cp\\u003eLeadership orientation to day-to-day activities\\u003c/p\\u003e\\n \\u003cp\\u003eDaily safety huddles, compliance reporting to the Board of Directors\\u003c/p\\u003e\\n \\u003cp\\u003eDigital quality dashboards\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePreoccupation with Failure\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eView near misses as opportunity to improve versus proof of success.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eQuality Risk Management patient safety incident reporting system\\u003c/p\\u003e\\n \\u003cp\\u003eCorporate Patient Safety Committee\\u003c/p\\u003e\\n \\u003cp\\u003eAdverse Event Reviews (Chart Reviews) \\u0026ndash; Patient Safety Action Plans\\u003c/p\\u003e\\n \\u003cp\\u003eNursing staff competency testing (physical assessment and communication)\\u003c/p\\u003e\\n \\u003cp\\u003eBest Practice Spotlight Organization\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eDeference to Expertise\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eValue insights from staff and physicians with the most pertinent safety knowledge over those with\\u0026nbsp;administrative status.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eReinventing Patient Care Councils \\u0026ndash; Continuous Quality Improvement Councils\\u003c/p\\u003e\\n \\u003cp\\u003eStuder practices\\u003c/p\\u003e\\n \\u003cp\\u003eStaff/Physician/Volunteer Engagement Survey\\u003c/p\\u003e\\n \\u003cp\\u003ePatient Engagement / Patient Family Advisors\\u003c/p\\u003e\\n \\u003cp\\u003eInterprofessional System Reviews\\u003c/p\\u003e\\n \\u003cp\\u003eCorporate and Program-specific Patient and Family Advisory Committees\\u003c/p\\u003e\\n \\u003cp\\u003eFocus groups\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eResilience\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePrioritize emergency training and plan for many unlikely but possible system failures.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePandemic Planning / Emergency Preparedness\\u003c/p\\u003e\\n \\u003cp\\u003eIncident Management Systems\\u003c/p\\u003e\\n \\u003cp\\u003eComprehensive staffing plans\\u003c/p\\u003e\\n \\u003cp\\u003eNursing Resource Teams / Workforce Forecasting\\u003c/p\\u003e\\n \\u003cp\\u003eSimulation/Escalation Training\\u003c/p\\u003e\\n \\u003cp\\u003eAccreditation tracer / audits\\u003c/p\\u003e\\n \\u003cp\\u003eActively planning redundancies within the system\\u003cbr\\u003e\\u0026nbsp;Emergency drills / mock code red/green/orange/blue\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eReluctance to Simplify\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eAccept that work is complex, with the potential to fail in new and unexpected way.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eInterprofessional and Cross Functional System Reviews\\u003c/p\\u003e\\n \\u003cp\\u003eHuman Factors Analysis\\u003c/p\\u003e\\n \\u003cp\\u003eIntegrated Risk Management\\u003c/p\\u003e\\n \\u003cp\\u003eFailure Mode Effect Analysis\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eNext, additional initiatives were planned and implemented to complete the \\u0026ldquo;whole system safety\\u0026rdquo; planning at HRH (see \\u003cstrong\\u003eSupplementary Table S1\\u003c/strong\\u003e in Supplementary Materials). While many initiatives were put into place at HRH, the overarching goal was to achieve the highest level of hospital safety as reported through the Hospital Harm Project. The Hospital Harm Project is a unique partnership between the Canadian Institute for Health Information (CIHI) and Healthcare Excellence Canada, annually reporting the unintended patient safety incidents in acute care hospitals that could have been prevented by complying with evidence-based practices [29]. The annual Hospital Harm report became an organizational focus for HRH and a key report for the HRH Board of Directors. Planning purposefully for long-term change at HRH, all initiatives included in the \\u003cstrong\\u003eSupplementary Table S1\\u003c/strong\\u003e have been maintained for a minimum of three years (including patient family advisor board representation as this implementation began in 2023). Ultimately, no initiatives were removed from the list, and all initiatives had control measures planned to ensure triggers would help teams recognize failure of adherence. The purpose of establishing controls within the planning process was to ensure long-term implementation success.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAim\\u003c/h2\\u003e \\u003cp\\u003eThe team undertook a study to specifically explore the whole system safety approach at HRH as an HRO. Thus, we translated HRO principles to explore the whole system safety approach at HRH as a high reliability organization to reduce preventable harm within the organization and incorporate Reason's foundational safety culture framework to explore domains that manifest in highly reliable daily operational practices.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eCase Study\\u003c/h3\\u003e\\n\\u003cp\\u003eA single-organization case study method was used and reported (see Appendix A [\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e]) to explore a deeper understanding of HRH and its safety approach. Single-organization studies have been noted as a legitimate means to develop and gain contextualized explanation and understanding of the phenomenon of interest [\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e]. Both qualitative analysis (i.e., hospital documentation) and quantitative analysis (using CIHI Hospital Harm results [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e]) were used to provide insights into the relationship between the two frameworks approach for safety, and the overall observed Hospital Harm measures with respect to patient safety outcomes. With respect to reflexivity, the authors (JY, BC) note that wherever possible, biases were acknowledged and an explicit part of discussions involved in coding throughout the document analysis phase.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eQualitative Document Analysis and Theoretical Triangulation\\u003c/h2\\u003e \\u003cp\\u003eA document analysis approach used for theoretical triangulation for this single-organization case study [\\u003cspan additionalcitationids=\\\"CR34\\\" citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e] based on close reading of all relevant publicly available hospital documents and data coding (using pre-set codes as defined with selected frameworks). Both qualitative and quantitative data were collected and used for this study, focus was primarily on publicly available resources to create a complementary and complete big-picture understanding of the improved Hospital Harm results experienced at HRH. For the qualitative phase, HRH-specific public documentation was reviewed using directed (deductive) document analysis. All institutional documents were compared against two separate frameworks relevant for patient safety through high reliability principles and Reason\\u0026rsquo;s safety sub-cultures [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eFor the qualitative analysis, we applied deductive document analysis to the data with respect to initiatives using the five HRO principles [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e] (\\u003cem\\u003eoperational sensitivity, pre-occupation with failure, deference to expertise, commitment to resilience\\u003c/em\\u003e, and \\u003cem\\u003ereluctance to simplify\\u003c/em\\u003e) as well as Reason\\u0026rsquo;s five sub-cultures of safety culture [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e] (\\u003cem\\u003eInformed Culture, Learning Culture, Flexible Culture, Reporting Culture, Just Culture\\u003c/em\\u003e). Conduct of the qualitative analysis, relevant internal documents for each of the strategies and initiatives were located and reviewed. The complete analysis of documents comprised of 45 regularly produced reports, 42 procedural documents, 24 policy documents, 22 training documents, 4 legislative requirements, 4 orientation manuals, 3 committee terms of references, 2 regularly conducted surveys, 1 electronic medical record manual, and 1 memorandum of understanding. A full list of documents can be accessed in \\u003cb\\u003eSupplementary Table S2\\u003c/b\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe year that the initiative was implementation was also included (and as Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e notes), many initiatives were in place prior to 2015. It is important to note that extracted statements from the documents in fact matched multiple codes in both frameworks. A second coder enlisted to code documents independently to increase trustworthiness of the final codes for analysis. All conflicting codes (less than 5%) were discussed between the two independent coders, using the same definitions for each of the principles and sub-cultures, and all codes were agreed upon through consensus. The results of analyzing the document analysis separately against each framework provided opportunity for theory triangulation interpretation including concepts that overlap and others that may contradict each other.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eQuantitative Analysis\\u003c/h3\\u003e\\n\\u003cp\\u003eFor the quantitative analysis to reflect a whole systems safety approach, we extracted the CIHI hospital harm rates from the CIHI portal, which include HRH data, as well as benchmarked provincial and national hospital rates, specifically, Ontario hospital rates and Canada\\u0026rsquo;s hospital rates. These hospital harm rates are reported as data extracted from various acute care health records (using primarily the CIHI Discharge Abstract Database) and initially reported as crude rates where the numerator is as the total number of patients experiencing harm during their admission, divided by total number of patients discharged per fiscal year [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e]. Important to note, CIHI definition for harm is not limited one singular category, but is in fact based on 31 different types of preventable harms, broken down into four major categories (Health-care / Medication-Associated Conditions such as pressure ulcers, medication errors; Health-Care\\u0026ndash;Associated Infections (such as hospital-acquired infections); Procedure-Associated Conditions (such as complications from surgery, like bleeding); and Patient Accidents (such as falls in hospital)\\u003csup\\u003e31\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe HRH harm rates for each of the four CIHI harm categories were then analyzed respectively; chi-squared (C\\u003csup\\u003e2\\u003c/sup\\u003e) test of independence was performed using the Canada-wide rates as the expected frequency and compared to the observed frequency. HRH rates for which the resulting p-value from the respective C \\u003csup\\u003e2\\u003c/sup\\u003e test was greater than 0.05 was considered comparable to Canada-wide rates, whereas any HRH rates where with the resulting p-values was below 0.05 indicated a significant difference between HRH rates and Canada-wide rates.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eAs noted, there are 56 initiatives that were implemented at HRH. The rest were implemented over the period of 2016 to 2025, with the largest group of new initiatives started and sustained since 2016. Most initiatives that were implemented post-2015 are based on the concept of leading indicators (i.e. proactive approach to safety) rather than lagging indicators (i.e. reactive organizational responses to safety). Drawing from the results of the deductive coding, we observe a high level of agreement of manifestation of HRO Principles and safety sub-cultures. The HRH initiatives listed in \\u003cstrong\\u003eSupplementary Table \\u003cspan class=\\\"InternalRef\\\"\\u003eS1\\u003c/span\\u003e\\u003c/strong\\u003e are assumed to contribute to the significant reduction of patient safety incidents. Emphasis on flexible culture highlights the agility and adaptability that is required for HROs.\\u003c/p\\u003e\\n\\u003cp\\u003eOverall, 56 different strategies were implemented at HRH from the period of 2015 to 2025, starting at the Wilson site (\\u003cstrong\\u003eSupplementary Table \\u003cspan class=\\\"InternalRef\\\"\\u003eS1\\u003c/span\\u003e\\u003c/strong\\u003e). In total, the strategies ensured a comprehensive whole-system approach to safety, highlighting the multiple HRO principles, and domains of safety culture as defined by Reason [\\u003cspan class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. For example, the planning and implementation of the Command Centre Generation 1 tiles (patient flow) support the HRO principles of \\u003cem\\u003esensitivity to operations, pre-occupation with failure, resilience\\u003c/em\\u003e, and \\u003cem\\u003ereluctance to simplify\\u003c/em\\u003e (\\u003cstrong\\u003eSupplementary Table \\u003cspan class=\\\"InternalRef\\\"\\u003eS1\\u003c/span\\u003e\\u003c/strong\\u003e, strategy #1). These tiles support a flexible culture where teams are in continuous reflection of patient flow, proactively and in-the-moment to prioritize and re-allocate resources that support maximizing hospital capacity.\\u003c/p\\u003e\\n\\u003cp\\u003eTo further illustrate a whole system approach, strategic nursing workforce planning (\\u003cstrong\\u003eSupplementary Table \\u003cspan class=\\\"InternalRef\\\"\\u003eS1\\u003c/span\\u003e\\u003c/strong\\u003e, strategy #20), is a major strategy for committing to and building organizational resilience through proactive staffing plans that ensure productive patient care delivery despite disruptions; however this strategy is functionally managed through the principle of \\u003cem\\u003esensitivity to operations, pre-occupation with failure, deference to expertise, resilience, and reluctance to simplify\\u003c/em\\u003e as individual units must report and manage staffing vulnerabilities, in addition to forecasting these needs [\\u003cspan class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e]. As such, a flexible culture is created, affording the ability to prioritize and re-allocate staffing as required to ensure safe patient care delivery.\\u003c/p\\u003e\\n\\u003cp\\u003eFigure \\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e provides an overview of total patients harmed as a crude ratio calculated against total discharged patients in each fiscal year between HRH and includes an aggregate harm score for all Ontario hospitals, as well as an aggregate harm score for all hospitals across Canada [\\u003cspan class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"char\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eIn 2014/15 the hospital harm rate for HRH was comparable to the Ontario and Canada aggregate scores, however there is a noticeable downward trend for HRH over the 2015/16 to 2018/19. The lowest rates of harm experienced by HRH were sustained for seven consecutive years. Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e provides the comparison of HRH rates against the Canadian hospital harm rates. In 2014/15, only medication errors at HRH were noted to be significantly lower than the Canadian hospital rate, which can be credited to the closed-loop medication system that was already in place at the time. By 2017/18, HRH hospital harm rates in all four categories of harm were significantly lower than the Canadian hospital rate.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003ctable id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n\\u003cp\\u003eChi-squared (C\\u003csup\\u003e2\\u003c/sup\\u003e) Test of Independence between HRH Rates of Harm versus the Canada-wide Rates of Harm per fiscal year\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003c/caption\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eHRH Medication/\\u003c/p\\u003e\\n\\u003cp\\u003eCondition-Associated Errors\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eHRH Infection-Associated Errors\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eHRH Patient Accidents\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eHRH Procedure-Associated Errors\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCanada-wide Hospital Medication/\\u003c/p\\u003e\\n\\u003cp\\u003eConditions-Associated Errors\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCanada-\\u003c/p\\u003e\\n\\u003cp\\u003ewide Hospital Infection-Associated Errors\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCanada-\\u003c/p\\u003e\\n\\u003cp\\u003ewide Hospital Patient Accidents\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCanada-wide Hospital Procedure-Associated Errors\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2014/15\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2.65\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2.30 (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.24 (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1.34 (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.65\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.09\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.21\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.33\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2015/16\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3.20\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.80 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.20 (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.10 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.72\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.06\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.19\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.37\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2016/17\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.90\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.00 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.20 (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.80 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.79\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.00\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.20\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.37\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2017/18\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.80\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.00 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.10 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.90 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.81\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.96\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.21\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.35\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2018 /19\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.10\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.60 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.10 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.70 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.83\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.91\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.22\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.33\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2019/20\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.00\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.50 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.10 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.80 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.93\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.91\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.23\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.34\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2020/21\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.20\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.80 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.10 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.70 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e3.27\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.09\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.26\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.43\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2021/22\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.00\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.60 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.10 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.70 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e3.35\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.20\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.26\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.34\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2022/23\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.10\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.90 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.10 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.90 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e3.37\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.26\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.27\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.33\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2023/24\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.00\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.70 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.10 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.70 (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e3.40\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.19\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.26\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.30\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2024/25\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1.00\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.80\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.10\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.70\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e(p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e3.36\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2.17\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0.26\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1.30\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003ctfoot\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd colspan=\\\"9\\\"\\u003eFootnote: The table provides a comparison of the year-over-year hospital harm rates broken down by the four major categories of hospital harm. The statistical significance using \\u003cstrong\\u003echi-squared independence test\\u003c/strong\\u003e between the HRH rates and Canada-wide hospital rates between the larger discharged patients against those that were discharged from HRH per each fiscal year. Statistically significant results have been bolded.\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tfoot\\u003e\\n\\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eAt the outset of the document analysis, the number of initiatives were counted per implementation year. Of note, 23 safety initiatives were already in place during 2015 \\u0026ndash; the largest set of new patient safety initiatives were then implemented in 2016, followed by the next largest set of safety initiatives in 2017. The last initiative which began in 2025 was the induction of a formal patient and family advisor as a board member of the hospital\\u0026rsquo;s Board Quality Assurance Committee \\u0026ndash; from the documents, however the work to bring a representative to the board committee began in 2023, and a Terms of Reference was established for the patient and family advisor to remain.\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003ctable id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\n\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n\\u003cp\\u003eNumber of Quality and Patient Safety Initiatives Implemented Per Year at HRH\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003c/caption\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eYear\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNumber of New Quality \\u0026amp; Patient Safety Initiatives at HRH\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTotal Number of Quality and Patient Safety Initiatives at HRH (percentage of all initiatives)\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2015\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e23 (41.1%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2016\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e10\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e33 (58.9%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2017\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e41 (73.2%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2018\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e4\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e45 (80.4%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2019\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e2\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e47 (83.9%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2020\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e5\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e52 (92.9%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2021\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e3\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e55 (98.2%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2022\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e55 (98.2%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2023\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e55 (98.2%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2024\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e55 (98.2%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2025\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"char\\\" char=\\\".\\\"\\u003e\\n\\u003cp\\u003e1\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e56 (100%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eDespite the many initiatives that were in place at the start of the 2015 timeframe (23 initiatives listed as per Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e), a large injection of new initiatives begun in 2016 (10 initiatives), and 2017 (8 initiatives). Of note, most initiatives that were implemented post-2015 are based on the concept of leading indicators (i.e. proactive approach to safety) rather than lagging indicators (i.e. reactive organizational responses to safety). Drawing from the results of the deductive coding, we observed a high level of agreement of manifestation of HRO Principles and safety sub-cultures. The HRH initiatives listed in Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e are assumed to contribute to the significant reduction of patient safety incidents.\\u003c/p\\u003e\\n\\u003cp\\u003eTable\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e provides an overview of safety initiatives against the five HRO principles and Reason\\u0026rsquo;s five sub-cultures for safety. It became quickly apparent that many of the safety initiatives that were implemented at HRH in fact crossed multiple principles as well as multiple sub-cultures. The high level of alignment supported the notion of synergy that could occur between the two frameworks in this single-organization case study.\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003eTable 4\\u003c/div\\u003e\\n\\u003ctable id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n\\u003cp\\u003eComparison of the Number of HRH Quality and Patient Safety Initiatives which aligned with Each of the HRO Principles and Reason\\u0026rsquo;s five sub-cultures of Safety Culture\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003c/caption\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003ctable id=\\\"Tabb\\\" border=\\\"1\\\"\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eHRO Principle\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNumber of Quality and Patient Safety Initiatives at HRH\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eProportion of Alignment\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003ePreoccupation with Failure\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e50\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e89.3%\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSensitivity to Operations\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e43\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e76.8%\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eReluctance to Simplify\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e38\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e67.9%\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCommitment to Resilience\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e36\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e64.3%\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eDeference to Expertise\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e34\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e60.7%\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n\\u003ctable id=\\\"Tabc\\\" border=\\\"1\\\"\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eReason\\u0026rsquo;s Sub-Culture Description\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNumber of Quality and Patient Safety Initiatives at HRH\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eProportion of Alignment\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eLearning Culture\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e46\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e82.1%\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eInformed Culture\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e45\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e80.4%\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eFlexible Culture\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e38\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e67.9%\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eReporting Culture\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e36\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e64.3%\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eJust Culture\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14.2%\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003c/table\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis single-organization case study examined institutional documents against two separate frameworks relevant for patient safety through high reliability principles and Reason\\u0026rsquo;s safety sub-cultures. The alignment between both frameworks provided meaningful opportunity to bring together the relevancy of two separate frameworks. Professional organizations such as the Registered Nurses\\u0026rsquo; Association of Ontario have also observed beneficial synergies in bringing together two separate frameworks (i.e. Knowledge-To-Action Framework and Social Movement Action Framework) as a successful way for healthcare organizations to support accelerated implementation of best practice guidelines [\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eWe identified 56 different strategies employed by the hospital, which ultimately contribute to whole system safety approach at HRH. The majority of strategies exhibit multiple HRO principles and the safety sub-cultures, which in turn improve delivery of reliable care. The study results suggests that the HRO principles clearly support the behavioral and operational patterns, which are embedded into policies, procedures, reports and education at HRH. By way of implementing many safety initiatives that reinforced constructs from both frameworks, the organization\\u0026rsquo;s contextual, social-technical and process components are likely to have in turn supported a mature safety culture \\u0026ndash; and we suggest that a mature safety culture has been critical to support and sustain the low hospital harm rates over seven years.\\u003c/p\\u003e \\u003cp\\u003eA large introduction of 10 initiatives occurred in 2016, followed by another 8 initiatives in 2017. These included beginning the reporting of safety huddles to the board of directors, interprofessional system reviews, nursing workforce planning and forecasting, simulations-based training, clinical practice leader development (including quality improvement and patient safety sciences), scholarly poster development, unit-specific quality dashboards, deep dive education sessions for the Board Quality Assurance Committee, creating a Quality \\u0026amp; Safety Framework as well as creating a Patient Safety Plan. Of note, safety huddles, workforce planning, simulations-based training, leader development, staff rounding, patient rounding, surgical safety checklists, and patient safety plan-development are meaningful with respect to leading indicators (proactively planning) for safety.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eOverall Contributors to HRH as a High Reliability Organization and Mature Safety Culture\\u003c/h2\\u003e \\u003cp\\u003eDrawing from the results of the deductive coding, we observed a high level of agreement of manifestation of HRO Principles and safety sub-cultures of the HRH initiatives (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Not only has there been a large number of safety initiatives put in place that contribute to whole safety system approach, but many of these initiatives are proactive in nature (e.g. surgical safety checklists, safety huddles to flag to management future safety risks) rather than reactive in nature (e.g. incident reporting). With increasing the number of proactive safety initiatives, this approach supports both individuals and systems in pre-emptively preventing incidents but may also have significantly improved the maturity of the organization\\u0026rsquo;s safety culture with respect to paying attention to both what went wrong and what could go wrong.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eConvergence between Frameworks\\u003c/h2\\u003e \\u003cp\\u003eFirstly, based on the cross-examination of the institutional documents against both frameworks, the highest level of overlap was observed between \\u003cem\\u003epre-occupation with failure (HRO principle)\\u003c/em\\u003e, with \\u003cem\\u003elearning culture (Reason)\\u003c/em\\u003e, both of these concepts place critical emphasis on examining mistakes, near misses, and potentially recognize signals to drive continuous quality improvement. Pre-occupation with failure tends to focus on patients, staff and leaders to constantly surveillance for difficult-to-detect signals that may underpin a larger concern. A learning culture will concurrently emphasize a general level of \\u0026ldquo;unease\\u0026rdquo; and opportunity for learning at all staff levels. Error reporting (for both patient-related or process-related issues), adverse events, and near misses have long been recognized as the greatest opportunities for organizational learning [\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e]. While harm or errors may have occurred, a learning culture will support opportunities to disseminate learnings not only as a result of an error, but also to prevent one of a similar nature from occurring in the future.\\u003c/p\\u003e \\u003cp\\u003eOne such opportunity for learning is interprofessional, cross-functional system reviews involve clinicians, non-clinicians, leaders and patient representatives in a deep-dive of the incident in question. What is unique at HRH are these actions for system reviews. While there is very little published in the literature with regards to interprofessional safety reviews, in the ICU, a standardized method (the Orion method inspired by the aeronautic industry) has been employed using long-term engagement with the direct care team [\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e]. Following this example, the HRH system review approach undertook a presentation-style chart review with all clinicians and non-clinicians (e.g. support service staff) who were actively involved in a safety incident to share their insights and perspectives that may have influenced decision-making or suggest process or policy-improvement opportunities that could prevent a similar incident from occurring in the future. An action plan was developed through consensus, and report back to all teams once process improvements are completed. This approach places a greater emphasis on process improvement based on a hierarchy of effectiveness [\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e] rather than a fallible individual (e.g. human factors perspective) and has since opened dialogue for setting up systems for safety, no matter how small the concern may be.\\u003c/p\\u003e \\u003cp\\u003eA second illustrative example of an initiative that aligns \\u003cem\\u003epre-occupation with failure\\u003c/em\\u003e and \\u003cem\\u003elearning culture\\u003c/em\\u003e is the patient-simulated physical assessment test, which all new nursing hires are expected to pass. This assessment test supports general recognition of missing early warning signs of deterioration [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e], as well as practicing structured communication leading to failure to rescue [\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e]. Despite the popularity of early warning systems-based research, most studies did not provide details to inform real-world adoption [\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e]. Newly hired staff are provided with rubrics and simulation scenarios to practice recognizing a clinical concern (as a combination of correct assessment technique and interpretation) and communicating the findings to another professional in a Situation-Background-Assessment-Recommendation (SBAR) format. Individuals can undertake the physical assessment test three times (including multiple practice shifts in between each test), as staff may have different prior work and education experiences prior to their hire at HRH, however the expectations for identifying early deterioration and accurately communicating the concerns appropriately are clear.\\u003c/p\\u003e \\u003cp\\u003eThe next greatest level of overlap from this analysis was \\u003cem\\u003eoperational sensitivity\\u003c/em\\u003e (HRO principle) and an \\u003cem\\u003eInformed sub-culture\\u003c/em\\u003e (Reason). What this alignment suggests is that both constructs are jointly reliant and functional based on generating frontline reporting of information and building increased situational awareness. Without surprise, \\u003cem\\u003eoperational sensitivity\\u003c/em\\u003e and \\u003cem\\u003einformed sub-culture\\u003c/em\\u003e reinforce the expectation of staff and leaders to remain as connected to operational details, no matter how miniscule the detail may be. When emphasis is placed on accurate, timely knowledge of frontline conditions through open communication, this mechanism in fact supports developing respect for knowledge authority rather than healthcare teams relying functionally on positional authority only [\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e]. A key example increasing situational awareness and acting on such safety information that is accomplished through the Command Centre; for example, vital sign changes over time and are captured electronically in the EMR, and early warning signs of deterioration are signaled to staff and leaders alike, by alerts that are triggered in Command Centre Generation 2 Tiles [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eAs another illustrative example for \\u003cem\\u003eoperational sensitivity (HRO principle)\\u003c/em\\u003e and \\u003cem\\u003einformed sub-culture\\u003c/em\\u003e (Reason) are mandated daily safety huddles \\u0026ndash; the frequency of the safety huddles is reported to the hospital board of directors as a control measure, but in fact the quality of the safety concerns raised in daily safety huddles are then addressed proactively. Daily organizational safety huddles have long been recognized as an important \\u0026ldquo;pause\\u0026rdquo; for situation awareness [\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e]. The operational sensitivity and informed sub-culture are recognized to improve problem-solving and optimal patient outcomes [\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e]. Of note, both of these examples are leading indicators for safety (i.e. proactive in identifying safety issues) \\u0026ndash; they are operationalized to include safety protocol actions in addition to just identifying safety risks.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDivergence between Frameworks\\u003c/h2\\u003e \\u003cp\\u003eInterestingly, the one principle between both frameworks that appears to have been realized the least between all HRO principles and safety sub-cultures at HRH is \\u003cem\\u003eJust Culture\\u003c/em\\u003e (16%). While this disparity may be interpreted as far less initiatives supporting Just Culture at HRH, most of the published literature with regards to Just Culture is largely theoretical in nature [\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e]. Murray [\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e] also notes that many organizations have noted challenges in interpreting, let alone implementing Just Culture. Internal discussions, and hundreds of site visits from international hospital leaders over the years have highlighted the complex nature of blame in the context of healthcare errors [\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e]. Within HRH, leaders have taken the stance that Just Culture is best positioned as assigning the appropriate level of culpability between individuals and the system they work in through an incident decision tree. For example, organizations should recognize that while clinicians\\u0026rsquo; endeavor to document their assessments and findings accurately as possible, an electronic medical record screen may be missing fields that are important to prompt key pieces of information. As such, organizations should work towards supporting employees making the right decisions, as well as using all opportunities to make process improvements systematically (e.g. document optimization).\\u003c/p\\u003e \\u003cp\\u003eThough this study explored two frameworks to help gain a deeper understanding of the whole system safety experience at HRH, we recognize the most significant limitation is with regards to the generalizability of the results. Our interpretations assist with nuanced understanding of how HRO principles and Reason\\u0026rsquo;s Safety Culture Framework are synergistic, supportive frameworks for a single organization. However, a clear opportunity has been identified for further research, which aligns with the gap in current literature.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eHRH, a large and complex hospital setting, has demonstrated that such an organization can achieve a significant reduction in preventable harm, and a hospital harm rate that has been sustained for multiple years as a testimony that it is possible to focus relentlessly on high reliability and safe patient care. These outcomes diverge from the typical shallow engagement with high reliability principles into sustained interconnected nature between persons delivering and overseeing care, safety process and practice improvements within an organization. Overall, directed document analysis against two synergistic frameworks has been insightful \\u0026ndash; the strategies listed that are used at HRH support positive implications and suggestions for policy, practice and future research directions for other healthcare settings. Especially with alignments discovered between \\u003cem\\u003epre-occupation with failure\\u003c/em\\u003e and \\u003cem\\u003elearning culture\\u003c/em\\u003e, and \\u003cem\\u003eoperational sensitivity\\u003c/em\\u003e and \\u003cem\\u003einformed sub-culture\\u003c/em\\u003e, these alignments speak to organizational cultures which choose to pay attention to small signals that may have large returns in safety for the future. Other organizations may also realize that with a chosen focus on implementing high reliability principles, they may inherently also be improving safety culture maturity as described by Reason\\u0026rsquo;s Safety Culture Framework. While further research would be beneficial to further understand the implementation and specific impact of both frameworks at play, specific additional efforts should be focused on how \\u003cem\\u003ejust sub-culture\\u003c/em\\u003e was successfully implemented and its role in promoting and sustaining a culture of safety [\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e].\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e \\u003ch2\\u003eEthics Review\\u003c/h2\\u003e \\u003cp\\u003eThe work undertaken in this organization was part of ongoing/continuous quality improvement using publicly available data, and no study participants were required. Institutional Review Board approval was not required in accordance to the hospital\\u0026rsquo;s research determination policy, as well as the Tri-Council Policy Statement 2 (TCPS-2, 2022) Protocol. Nonetheless, an A pRoject Ethics Community Consensus Initiative (ARECCI) screening was completed, resulting in a score of 0.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eConsent for publication:\\u003c/strong\\u003e \\u003cp\\u003eNot applicable.\\u003c/p\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003ch2\\u003eCompeting Interests:\\u003c/h2\\u003e \\u003cp\\u003eAll authors have declared no conflict of interest.\\u003c/p\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003ch2\\u003eAuthor Details:\\u003c/h2\\u003e \\u003cp\\u003e \\u003csup\\u003e1\\u003c/sup\\u003eHumber River Health, Toronto, Canada\\u003c/p\\u003e \\u003cp\\u003e \\u003csup\\u003e2\\u003c/sup\\u003eQueen\\u0026rsquo;s University, Kingston, Canada\\u003c/p\\u003e \\u003cp\\u003e \\u003csup\\u003e3\\u003c/sup\\u003eUniversity of Toronto, Toronto, Canada\\u003c/p\\u003e \\u003c/p\\u003e\\u003ch2\\u003eFunding:\\u003c/h2\\u003e \\u003cp\\u003eThis study received no external funding\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eJ.Y. was responsible for design of the study, data processing. J.Y. and A.Z. were responsible for the analysis of the results and writing the manuscript. B.E.C. revised this manuscript.\\u003c/p\\u003e\\u003ch2\\u003eAcknowledgement\\u003c/h2\\u003e\\u003cp\\u003eThe authors would like to acknowledge the overwhelming support of the Board of Directors, Senior Management Team, all clinical and non-clinical teams, clinical practice leaders, and volunteers.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eDocuments used for this analysis are publicly available, and can be made available upon request to the corresponding author.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eWeick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed. San Francisco: Jossey-Bass; 2007.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMyers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf. 2022;31(12):845\\u0026ndash;8. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1136/bmjqs-2021-014141\\u003c/span\\u003e\\u003cspan address=\\\"10.1136/bmjqs-2021-014141\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCantu J, Tolk J, Fritts S, Gharehyakheh A. High Reliability Organization (HRO) systematic literature review: Discovery of culture as a foundational hallmark. J Contingencies Crisis Manag. 2020;28(4):399\\u0026ndash;410. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1111/1468-5973.12293\\u003c/span\\u003e\\u003cspan address=\\\"10.1111/1468-5973.12293\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCantu J, Tolk J, Fritts S, Gharehyakheh A. Interventions and measurements of highly reliable/resilient organization implementations: A literature review. Appl Ergon. 2021;90. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1016/j.apergo.2020.103241\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.apergo.2020.103241\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCincinnati Children\\u0026rsquo;s. Becoming a high reliability organization. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.cincinnatichildrens.org/research/divisions/j/anderson-center/safety/methodology/high-reliability\\u003c/span\\u003e\\u003cspan address=\\\"https://www.cincinnatichildrens.org/research/divisions/j/anderson-center/safety/methodology/high-reliability\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91:459\\u0026ndash;90. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1111/1468-0009.12023\\u003c/span\\u003e\\u003cspan address=\\\"10.1111/1468-0009.12023\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWorld Health Organization. Global patient safety action plan 2021\\u0026ndash;2030. 2021. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan\\u003c/span\\u003e\\u003cspan address=\\\"https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRotteau L, Goldman J, Shojania KG, et al. Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. BMJ Qual Saf. 2022;31(12):867\\u0026ndash;77. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1136/bmjqs-2021-013938\\u003c/span\\u003e\\u003cspan address=\\\"10.1136/bmjqs-2021-013938\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGoldstein DH, Nyce JM, Van Den Kerkhof EG. Safety perceptions of health care leaders in 2 Canadian academic acute care centers. J Patient Saf. 2017;13(2):62\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMcDonald N, McKenna L, Vining R, Doyle B, Liang J, Ward M, Ulfvengren P, Geary U, Guilfoyle J, Shuhaibar A. Evaluation of Access-Risk-Knowledge (ARK) Platform for Governance of Risk and Change in Complex Socio-Technical Systems. Int J Environ Res Public Health. 2021;18:12572.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWard ME, Daly A, McNamara M, Garvey S, Teeling SP. A Case Study of a Whole System Approach to Improvement in an Acute Hospital Setting. Int J Environ Res Public Health. 2022;19(3):1246.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFord JL. Revisiting high-reliability organizing: obstacles to safety and resilience. Corp Commun. 2018;23(2):197\\u0026ndash;211. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1108/CCIJ-04-2017-0034\\u003c/span\\u003e\\u003cspan address=\\\"10.1108/CCIJ-04-2017-0034\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVeazie S, Peterson K, Bourne D. Evidence brief: Implementation of high reliability organization principles. Washington, DC: \\u003cem\\u003eU.S. Department of Veterans Affairs, Health Services Research and Development Service\\u003c/em\\u003e; 2019. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK542883/\\u003c/span\\u003e\\u003cspan address=\\\"https://www.ncbi.nlm.nih.gov/books/NBK542883/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSimpson D, Hamilton S, McSherry R, McIntosh R. Measuring and Assessing Healthcare Organisational Culture in England\\u0026rsquo;s National Health Service: A Snapshot of Current Tools and Tool Use. \\u003cem\\u003eHealthcare\\u003c/em\\u003e 2019, 7, 127.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eReason J. Achieving a safe culture: Theory and practice. Work stress. 1998;12(3):293\\u0026ndash;306.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLevett-Jones T, Hoffman K, Dempsey J, Jeong SYS, Noble D, Norton CA, et al. The \\u0026lsquo;five rights\\u0026rsquo; of clinical reasoning: An educational model to enhance nursing students\\u0026rsquo; ability to identify and manage clinically \\u0026lsquo;at risk\\u0026rsquo; patients. Nurse Educ Today. 2010;30(6):515\\u0026ndash;20. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1016/j.nedt.2009.10.020\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.nedt.2009.10.020\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCollins BE. Reducing Hospital Harm: Establishing a Command Centre to Foster Situational Awareness. Healthc Q. 2022;25(2):75\\u0026ndash;81. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.12927/hcq.2022.26885\\u003c/span\\u003e\\u003cspan address=\\\"10.12927/hcq.2022.26885\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHumber River Health. Quality Safety Framework. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.hrh.ca/wp-content/uploads/2023/01/Quality-and-Safety-Framework.pdf\\u003c/span\\u003e\\u003cspan address=\\\"https://www.hrh.ca/wp-content/uploads/2023/01/Quality-and-Safety-Framework.pdf\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHumber River Health. Patient Safety Plan. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.hrh.ca/wp-content/uploads/2025/10/Patient-Safety-Plan-FY2025-26.pdf\\u003c/span\\u003e\\u003cspan address=\\\"https://www.hrh.ca/wp-content/uploads/2025/10/Patient-Safety-Plan-FY2025-26.pdf\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHollnagel E. Safety-i and safety-ii: the past and future of safety management. First edition. Boca Raton, FL: CRC Press, an imprint of Taylor and Francis; 2014.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRasmussen J. Risk management in a dynamic society: a modelling problem. Saf Sci. 1997;27(2):183\\u0026ndash;213.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHealthcare Excellence Canada. The Canadian Quality \\u0026amp; Patient Safety Framework for Health Services. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.healthcareexcellence.ca/media/e3dkkwos/cpsi-10001-cqps-framework-english_fa_online-final-ua.pdf\\u003c/span\\u003e\\u003cspan address=\\\"https://www.healthcareexcellence.ca/media/e3dkkwos/cpsi-10001-cqps-framework-english_fa_online-final-ua.pdf\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316(7138):1154\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDonabedian A. Evaluating the quality of medical care. \\u003cem\\u003eMilbank Memorial Fund Q\\u003c/em\\u003e. 1966;44(3)(suppl):166-206. Reprinted in \\u003cem\\u003eMilbank Q\\u003c/em\\u003e. 2005;83(4):691‐729.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGrinspun D, Bajnok I. Registered Nurses\\u0026rsquo; Association of Ontario issuing body. Sigma Theta Tau International issuing body. Transforming nursing through knowledge: best practices for guideline development, implementation science, and evaluation. Indianapolis, IN: Sigma Theta Tau International; 2018.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZhang J, Johnson TR, Patel VL, Paige DL, Kubose T. Using usability heuristics to evaluate patient safety of medical devices. J Biomed Inform. 2003;36(1):23\\u0026ndash;30. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1016/S1532-0464(03)00060-1\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/S1532-0464(03)00060-1\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePatriarca R, Di Gravio G, Woltjer R, Costantino F, Praetorius G, Ferreira P et al. Framing the FRAM: A literature review on the functional resonance analysis method. Saf Sci. 2020;129.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWachter RM. Understanding patient safety [Internet]. 2nd ed. New York, N.Y: McGraw-Hill Education LLC.,; 2012.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAarons G, Hurlburt M, Horwitz S. Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors. Adm Ment Health. 2011;38:4\\u0026ndash;23.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRuneson P, H\\u0026ouml;st M. Guidelines for conducting and reporting case study research in software engineering. Empir Softw engineering: Int J. 2009;14(2):131\\u0026ndash;64.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWelch C, Paavilainen-M\\u0026auml;ntym\\u0026auml;ki E, Piekkari R, Plakoyiannaki E. Reconciling theory and context: How the case study can set a new agenda for international business research. J Int Bus Stud. 2022;53(1):4\\u0026ndash;26.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCanadian Institute for Health Information. Hospital Harm Results, 2014\\u0026ndash;2015 to 2024\\u0026ndash;2025. Ottawa, ON: CIHI; 2025.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBowen GA. Document Analysis as a Qualitative Research Method. Qualitative Res J. 2009;9(2):27\\u0026ndash;40. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.3316/QRJ0902027\\u003c/span\\u003e\\u003cspan address=\\\"10.3316/QRJ0902027\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTaylor M, Garner P, Oliver S, Desmond N. Use of qualitative research in World Health Organisation guidelines: a document analysis. \\u003cem\\u003eHealth Res Policy Syst\\u003c/em\\u003e. 2024;22(1):44. Published 2024 Apr 4. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1186/s12961-024-01120-y\\u003c/span\\u003e\\u003cspan address=\\\"10.1186/s12961-024-01120-y\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eArias Valencia MM. Principles, Scope, and Limitations of the Methodological Triangulation. Investigaci\\u0026oacute;n y educaci\\u0026oacute;n en enfermer\\u0026iacute;a. 2022;40(2).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eYoon J, Hutchinson D, Marville-Williams C, et al. Case Study: The Impact of Nursing Professional Practice during the COVID-19 Pandemic at a Large Community Hospital in Canada. Nurs Leadersh (Tor Ont). 2022;35(3):48\\u0026ndash;65. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.12927/cjnl.2022.27003\\u003c/span\\u003e\\u003cspan address=\\\"10.12927/cjnl.2022.27003\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRegistered Nurses\\u0026rsquo; Association of Ontario. Two Complementary Frameworks. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://rnao.ca/bpg/leading-change-toolkit/two-complementary-frameworks-bak\\u003c/span\\u003e\\u003cspan address=\\\"https://rnao.ca/bpg/leading-change-toolkit/two-complementary-frameworks-bak\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMurray JS, Lee J, Larson S, Range A, Scott D, Clifford J. Requirements for implementing a \\u0026lsquo;just culture\\u0026rsquo; within healthcare organisations: an integrative review. BMJ Open Qual. 2023;12(2):e002237. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1136/bmjoq-2022-002237\\u003c/span\\u003e\\u003cspan address=\\\"10.1136/bmjoq-2022-002237\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWoodier N, Burnett C, Moppett I. The Value of Learning From Near Misses to Improve Patient Safety: A Scoping Review. J Patient Saf. 2023;19(1):42\\u0026ndash;7. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1097/PTS.0000000000001078\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/PTS.0000000000001078\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChapuis C, Chanoine S, Colombet L, Calvino-Gunther S, Tournegros C, Terzi N, et al. Interprofessional safety reporting and review of adverse events and medication errors in critical care. Ther Clin Risk Manag. 2019;15:549\\u0026ndash;5. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.2147/TCRM.S188185\\u003c/span\\u003e\\u003cspan address=\\\"10.2147/TCRM.S188185\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCafazzo JA, St-Cyr O. From Discovery to Design: The Evolution of Human Factors in Healthcare. \\u003cem\\u003eHealthcare Quarterly\\u003c/em\\u003e (Toronto, Ont). 2012;15(SP1):24\\u0026ndash;9. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.12927/hcq.2012.22845\\u003c/span\\u003e\\u003cspan address=\\\"10.12927/hcq.2012.22845\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChua WL, Legido-Quigley H, Ng PY, McKenna L, Hassan NB, Liaw SY. Seeing the whole picture in enrolled and registered nurses\\u0026rsquo; experiences in recognizing clinical deterioration in general ward patients: A qualitative study. Int J Nurs Stud. 2019;95:56\\u0026ndash;64. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1016/j.ijnurstu.2019.04.012\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.ijnurstu.2019.04.012\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMcGhee TL, Weaver P, Solo S, Hobbs M. Vital signs reassessment frequency recommendation. Nurs Manag. 2016;47(9):11\\u0026ndash;2. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1097/01.NUMA.0000491132.98848.22\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/01.NUMA.0000491132.98848.22\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGhaferi AA, Dimick JB. Importance of teamwork, communication and culture on failure-to-rescue in the elderly. Br J Surg. 2016;103(2):e47\\u0026ndash;51. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1002/bjs.10031\\u003c/span\\u003e\\u003cspan address=\\\"10.1002/bjs.10031\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eEsmaeilzadeh S, Lane CM, Gerberi DJ, Wakeam E, Pickering BW, Herasevich V, et al. Improving In-Hospital Patient Rescue: What Are Studies on Early Warning Scores Missing? A Scoping Review. Crit Care Explorations. 2022;4(2):e0644. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1097/CCE.0000000000000644\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/CCE.0000000000000644\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBurkoski V, Yoon J. Continuous quality improvement: a shared governance model that maximizes agent-specific knowledge. \\u003cem\\u003eNurs Leadersh (Tor Ont)\\u003c/em\\u003e. 2013;26 Spec No 2013:7\\u0026ndash;16. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.12927/cjnl.2013.23363\\u003c/span\\u003e\\u003cspan address=\\\"10.12927/cjnl.2013.23363\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFencl JL, Willoughby C. Daily Organizational Safety Huddles: An Important Pause for Situational Awareness. AORN J. 2019;109(1):111\\u0026ndash;8. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1002/aorn.12571\\u003c/span\\u003e\\u003cspan address=\\\"10.1002/aorn.12571\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBurr KL, Stump AA, Bladen RC, O\\u0026rsquo;Brien PR, Lemon BJ, Tearl DK, et al. Twice-Daily Huddles Improves Collaborative Problem Solving in the Respiratory Care Department. Respir Care. 2021;66(5):822\\u0026ndash;8. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.4187/respcare.07717\\u003c/span\\u003e\\u003cspan address=\\\"10.4187/respcare.07717\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCollins ME, Block SD, Arnold RM, Christakis NA. On the prospects for a blame-free medical culture. \\u003cem\\u003eSocial Science \\u0026amp; Medicine\\u003c/em\\u003e (1982). 2009;69(9):1287\\u0026ndash;90. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003edoi.org/10.1016/j.socscimed.2009.08.033\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.socscimed.2009.08.033\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"high reliability organization, patient safety, safety culture\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8800008/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8800008/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eHumber River Health (HRH) is a Toronto Academic Health Sciences Network affiliated community hospital serving a catchment of 850,000 individuals in northwest Toronto. Despite having one of the nation’s busiest emergency departments and admitted volumes in Canada, the hospital leadership, physicians and staff designed and implemented 56 strategies as part of its High Reliability Organization (HRO) journey.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eComparison of the hospital’s harm rates versus Canada-wide hospital harm rates were calculated using Chi-squared independence test. As a single-organization case study, document analysis was undertaken to itemize safety strategies, then theoretical triangulation was completed to observe convergence and divergence between the HRO principles of Reason’s Safety Culture Framework.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe hospital demonstrated a shift in hospital harm rates (2.2%), which was significantly below the provincial (6.1%) and national (6.2%) peer averages (p \\u0026lt; 0.05). With respect to theoretical triangulation of the 56 implemented safety strategies, a high level of convergence between the two frameworks were observed at (HRH): HRO principle of pre-occupation with failure (89.3%) with Reason’s learning culture sub-culture (82.1%); HRO principle of sensitivity to operations (76.8%) with Reason’s informed sub-culture (80.4%); HRO principle of reluctance to simplify (67.9%) with Reason’s flexible sub-culture (67.9%); HRO principle of commitment to resilience (64.3%) with Reason’s reporting sub-culture (64.3%). Divergence was observed between the HRO principle of deference to expertise (60.7%) and Reason’s just culture (14.2%).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe explored the hospital experience and applied analysis of HRO Principles and Reason’s Safety Culture Framework. A high level of alignment between both frameworks were observed, and we encourage organizations on a HRO journey to also conscientiously adopt strategies supporting safety culture as the fifth HRO Principle and support the maturity of whole system safety.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTrial Registration: N/A\\u003c/strong\\u003e\\u003c/p\\u003e\",\"manuscriptTitle\":\"Case study: Understanding whole system safety through theory triangulation of high reliability organization principles and a safety culture framework at one of Canada’s safest hospitals\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-27 06:29:57\",\"doi\":\"10.21203/rs.3.rs-8800008/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-08T20:55:16+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"251279956088193778908645071149446682273\",\"date\":\"2026-03-12T10:50:37+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-02-20T14:40:31+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-02-10T06:50:41+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-02-10T06:32:39+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-02-10T06:29:31+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Health Services Research\",\"date\":\"2026-02-05T17:57:34+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"b8588a05-9f14-4f30-8482-5e70a09d15a6\",\"owner\":[],\"postedDate\":\"February 27th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-02-27T06:29:57+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-02-27 06:29:57\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8800008\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8800008\",\"identity\":\"rs-8800008\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}