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

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