High reliability organisations achieve high levels of safety and performance in the face of considerable hazards and operational complexity.1 The original studies by the Berkeley Group, which looked at nuclear power, naval aviation, and air traffic control, have been influential and inspired much comment and interpretation. High reliability organisations are frequently referenced as models to which health care should aspire, particularly because the environments and challenges are similar.1 2 3

Meeting the challenges of high reliability operations requires accountability, strong basic procedures, multiple procedural checks, and continual communication between operators.2 3 For example, during critical operations on naval carriers, multiple checks and observations by different people ensure that dangerous conditions are detected rapidly. “Buddy” systems, in which individuals monitor each other’s performance, are used to guard against unsafe actions. High reliability organisations also engage in varied training and simulation activities for a broad range of operational scenarios (such as deck fires on aircraft carriers) to prepare for crises and foster a flexible problem …