Attention in medicine, fire service, and law enforcement has come to risk mitigation and improving safety. Scattered throughout these services, individuals have come to learn that safety and risk mitigation best develop in a culture that supports front-line workers. This safety culture results in a highly reliable organization. There are those who would argue that tight control and micro-managing with a more authoritarian approach will keep decisions in the hands of experts. In this manner they would ensure safety. There is research that supports those who argue for decision migration, safety culture, and cooperative approach to develop a high reliability organization.

As technology becomes more complex and pervasive, we can now address uncommon situations in a productive manner. However the same technology can itself cause uncommon, catastrophic situations such as Exxon Valdez, Three Mile Island Nuclear Power Plant incident, and the Challenger Shuttle tragedy. In these situations one may find that evidence-based protocols and policies do not exist. However, there are evidence-based processes that one can use during an evolving disaster.

In the search for competitive advantage in an increasingly dynamic healthcare market, the ability to distinguish one's organization on some key factor is increasingly critical. Establishing and sustaining a high-reliability organization (HRO) offers one possible and under-utilized approach that can be seen by healthcare customers and stakeholders as an important and distinguishing factor.

Based on previous research by Perrow (1984), Weick and Roberts (1993), and other work by Roberts in the 1990s, HROs can be defined as organizations which have fewer than normal accidents. This decrease in accidents occurs through change in culture. Technology has some influence but not in isolation, nor without a change in the organization's culture. Roberts and her colleagues have defined the characteristics of organizations that have fewer failures than expected and their implications for organizational design.

In 1984, Perrow investigated "normal accidents." He concluded that while all organizations would eventually have accidents because of their complexity and interdependence, some organizations were remarkably adept at avoiding them. The question that Roberts sought to answer in her stream of research is why do some organizations not have as many failures as others?

From this question grew the definition and characteristics of HROs. At this point in its development, the research has identified some key characteristics of HROs. These include organizational factors (i.e., rewards and systems that recognize costs of failures and benefits of reliability), managerial factors (i.e., communicate the big picture), and adaptive factors (i.e., become a learning organization) (Grabrowski & Roberts, 2000). More specifically, HROs actively seek to know what they don't know, design systems to make available all knowledge that relates to a problem to everyone in the organization, learn in a quick and efficient manner, aggressively avoid organizational hubris, train organizational staff to recognize and respond to system abnormalities, empower staff to act, and design redundant systems to catch problems early (Roberts and Bea, 2001). In other words, an HRO expects its organization and its sub-systems will fail and works very hard to avoid failure while preparing for the inevitable so that they can minimize the impact of failure.