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Patient safety is an important  focus for health care providers of all stripes. It has huge impacts both financial and personal, and affects patients, but also doctors, nurses, and even society as a whole.

The best patient safety comes from a wholistic High Reliability Organizing (HRO) mindset.  HRO is the methodology that supports patient safety.

Dr. Pisters own words accurately describe why HRO is so critical to health care systems.  “… neither the physician nor the hospital had policies and protocols in place to deal with the conflicting information.”  In HRO terms, there was no “preoccupation with failure”.

With caring, forward thinking doctors like Peter Pisters, HRO can take root in an organization. And when we read about the impact on the patient and the care givers, we should all be asking our health care systems if they practice HRO. If they don’t, they are ignoring patient safety.

“The patient was okay but that moment was like no other in my career. I felt horrible. I felt humiliated. I felt such grief. I could not believe that I could possibly commit an error like that. And as I began to think about this in greater detail, I began to realize that yes, I had committed an error, but multiple systems had failed this patient.”


Dr. Peter Pisters

President & CEO , University Health Network (UHN)