The Zero Harm Imperative: High Reliability in Healthcare & Aviation

Every time you step into a new facility or care for a patient in an unfamiliar environment, you’re performing work that demands compassion, confidence, and precision. Travel clinicians operate in some of the most complex, high-pressure healthcare settings where even small variations in communication, workflow, or team dynamics can have a direct impact on patient safety. 

Meanwhile, there’s another industry where lives also depend on near-flawless execution: aviation. What aviation and healthcare share is a common truth: when things go wrong, they can go catastrophically wrong. But aviation’s transformation over the past several decades offers a powerful blueprint for what safe, reliable care can look like when an entire industry commits to “zero harm” as a non-negotiable standard.

This article explores the principles of High-Reliability Organizations (HROs), a framework that has reshaped aviation’s approach to safety, and what it means for clinicians on the front lines of care. You’ll learn how tools like checklists, team communication models, redundancy systems, and a true culture of safety became the backbone of one of the safest industries in the world. More importantly, you’ll see how those same principles apply directly to the work you do every day as a traveler.

Whether you’re at 30,000 feet or at the bedside, one thing remains constant: safety is paramount and core to your mission as a clinician.

Anyone who enters a healthcare facility or takes a flight expects safety. What does it take to get there?

Anyone stepping onto a plane or entering a hospital expects an absolute guarantee of safety. But what does it take to consistently achieve that outcome in environments that are high-stress, highly complex, and inherently high-risk?

The answer lies in adopting the principles of HROs, a framework that explains why certain industries, where the cost of error is catastrophic, successfully prevent failure despite massive complexity.

As sociologist Dr. Paul Bataldan noted,

HRO principles provide the blueprint for a system designed for safety.

Shared stakes and the cost of error

Healthcare and the airline industry are classic HRO examples because they share an unforgiving, high-risk environment; however, the landmark 1999 report, To Err Is Human, served as a stark realization that healthcare, unlike comparable high-risk industries like aviation, had a long way to go in achieving consistent safety. This report highlighted the alarmingly high number of preventable medical errors, underscoring the need for a fundamental shift in safety culture. 

Recent research confirms that while enthusiasm for the HRO journey remains high, the actual, consistent implementation across healthcare is often superficial, indicating that there is ‘still a long way left to go’³.

Both industries operate in an unforgiving environment defined by two factors:

1. High Opportunity for Error: Operations involve complicated processes, advanced technology, and human interaction.

2. Unforgiving Results: Failures lead to sentinel events, including patient death in healthcare, or crash and mass casualty in aviation.

The 1977 Tenerife runway collision, which killed 583 people, serves as aviation’s defining "wake-up call." This disaster resulted from poor visibility, unclear communication, and procedural violations and catalyzed a revolutionary shift toward a Culture of Safety that now underpins modern aviation.

The core lesson for both sectors is simple: the focus must be on achieving ZERO HARM.

Image source: @MaydayAirDisaster

5 principles of high-reliability organizations

HRO theory was pioneered by Karl Weick and Kathleen Sutcliffe, which outlines five characteristics that organizations must embrace to anticipate and contain the unexpected.

Activities consistent with HRO Theory:

• Understand the current situation (daily huddles, leader rounding, team boards)

• Encourage Incident reporting and provide follow-up 

• Encourage Just Culture, speak up campaigns and patient, family engagement

• Conduct simulation training

Structural and operational lessons from aviation

The application of HRO principles drives specific operational similarities between the two industries, providing a blueprint for managing complexity and risk in healthcare.

• Standardized guidelines and protocols: Both industries rely heavily on predictable, repeatable systems. Consistent operation is ensured by adherence to multiple standardized guidelines and regulations, from surgical checklists to pre-flight procedures.

• Need for redundancy: Build in multiple layers of redundancy (contingency plans) in control, equipment, and information systems to manage unexpected events effectively. 

• Focus on Teamwork and communication: Emphasize the critical importance of clear, structured communication (e.g., SBAR and repeat/read-back/check-back in healthcare, Crew Resource Management/CRM in aviation) and effective handoffs to maintain situational awareness and prevent critical information loss.

• Use of checklists and tools: Use simple, powerful tools like checklists (adapted in healthcare for surgery, infection control, etc.) to reduce cognitive load and ensure all critical tasks are completed correctly, every time.

• Data-driven preventive maintenance: The programmed preventive inspection protocols in aviation (like the pre-flight walk-around and cockpit checklist) are meticulously engineered based on historical performance data, failure analysis, and maintenance investigations. This systematic data collection enables consistent reliability tracking and the ongoing refinement of techniques, ensuring operational stability by identifying minor discrepancies before they evolve into uncontrollable crises. Risk assessment tools—such as for falls, pressure injury, and the Modified Early Warning Signs (MEWS)—are embedded in the EMR to help clinicians intervene sooner and prevent patient deterioration or injury.

• Regulatory oversight: Both industries employ skilled and certified personnel and are overseen by rigorous regulatory authorities (e.g., FAA, CMS, state health departments) that set and enforce mandatory safety standards, providing an external check on organizational performance.

The shift: learning from excellence

We tend to spend the majority of our time evaluating unacceptable outcomes and determining where people deviated from the norm; however, staff are constantly making subtle, successful adaptations to daily complexities, and these variations in performance still lead to acceptable outcomes.

The essential next step for healthcare is transitioning from a blaming system to a learning system. This means expanding our focus to include learning from excellence, studying what people do to make things go right. By recognizing and reinforcing high-reliability behaviors and designing systems that function as intended even under pressure, we recognize excellence and accelerate organizational safety.

As Dr. Don Berwick, President Emeritus and Senior Fellow at the Institute for Healthcare Improvement (IHI), summarized when describing the impact of a commitment to safety:

References

1. Hyman, D. (2025, November 2). High reliability and harm prevention: From theory to practice. [Presentation, University of Pennsylvania]. Chief Quality Officer Lecture Series, Children’s Hospital of Philadelphia, Philadelphia, PA.
2. Institute of Medicine (IOM). (1999). To err is human: Building a safer health system. National. Academies Press.
3. Myers, C. G., & Sutcliffe, K. M. (2022). High reliability organising in healthcare: still a long way left to go. BMJ Quality & Safety, 31(12), 845–848. https://doi.org/10.1136/bmjqs-2021-014141.
4. Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected (3rd ed.). John Wiley & Sons.