High reliability organizations and healthcare safety outcomes on patients and staff: Scoping review

Adverse events such as medication errors and staff injuries are prevalent in healthcare and contribute to patient harm and staff burnout. To enhance safety, organizations implemented the high-reliability organization (HRO) principles which aim to maintain low rates of adverse events while managing complex processes. These principles include sensitivity to operations, preoccupation with failure, reluctance to simplify, resilience, and deference to expertise. To explore evidence on HRO implementation and its impact patient and staff safety outcomes in healthcare. A scoping review of English-language studies published from 2016 to 2025. A librarian was consulted to develop electronic search strategies. Three databases were utilized to identify the relevant studies. Inclusion criteria were studies on HRO implementation in healthcare and safety outcomes on patient or staff. Two reviewers independently screened titles and abstracts, assessed full texts, and extracted data using the Joanna Briggs Institute (JBI) data extraction tool, with a third reviewer available to resolve disagreements. Of 3,305 studies retrieved, eleven met inclusion criteria. The studies focused on patient safety (e.g., medication errors, falls; n = 6). Two explored staff perceptions of patient safety; two assessed both staff perceptions and patient outcomes. One addressed staff safety. HRO implementation was associated with fewer adverse events, positive staff perceptions on patient safety, and improved psychological safety. Evidence suggests that HRO implementation is positively associated with improved patient safety and staff psychological safety. However, evidence on their impact on staff physical safety remains limited.