Table 2 Principles of high reliability organizing applied to the intensive care unit

Preoccupation with failure

Establish immediate post-code debriefings.

Include likely mechanisms of each patient's decompensation in sign-out rounds.

Engage in regular performance benchmarking.

Encourage blameless reporting of near failures and failures.

Use detailed analysis of incidents and errors for potential improvements in processes.

Reluctance to simplify

Be aware of cognitive bias in diagnosis and work to avoid premature diagnostic closure.

Maintain and revisit broad differential diagnoses.

Use multidisciplinary analyses as a basis for decision making.

Resist the tendency to ascribe only one cause to incidents and errors.

Sensitivity to operations

Maintain awareness of the patient's overall condition rather than focus on one particular problem or organ system.

Use tools that facilitate information sharing between team members (that is, electronic medical records).

Monitor unit-wide and hospital-wide conditions, such as bed availability, personnel shortages, and unit acuity fluctuations.

Resilience

Emphasize the importance of working together in multidisciplinary teams.

Encourage flexibility in team members to accommodate changes in unit acuity or hospital resources.

Explicitly include training around how to manage unexpected events in ICU staff educational training.

Deference to expertise

Foster knowledge of team members' particular strengths and weaknesses, including specialized services (that is, ability to manage a balloon pump).

Use appropriate clinical pathways and protocols (that is, nursing-driven sedation and respiratory therapist-led weaning protocols).

Institute multidisciplinary rounds on which nursing, respiratory therapy, pharmacy, and families have active voices and full participation.