Table 2.

HRT and NAT Analyses of Patient Safety Practices

Patient Safety Practice	Analysis within HRT Frame	Analysis within NAT Frame
Double-checking medications	Incorporates redundancy	Constrained by limits of social redundancy
	Exemplifies a cultural norm	Can hinder and delay problem detection
	Creates formal procedures to assure reliability	Can lower vigilance
Crew resource management (CRM)	Enables people with critical expertise and information to make decisions	Seeks to make risky technologies safer, not reduce their catastrophic potential
	Facilitates flexible responses to unexpected situations	Better suited for loosely coupled technologies
	Incorporates reward systems and cultural norms that support speaking up to authority	Relies on interpersonal communication skills; these are necessary but not sufficient to identify safety threats
Computerized physician order entry (CPOE)	Provides a method for gathering error data for top managers	May reduce interactive complexity, but will increase tight coupling
	May hinder open communication among different professionals	Reduces errors from simple component failures
		Adds to risk of infrequent, high consequence errors affecting many patients
		Illustrates limitations of redundancy “added on” to original design
Incident reporting	Requires end to “culture of blame”	“Politics of blame” hinders reporting
	Relies on individual capacity to engage in valid sensemaking	Incentives lacking for reporting incidents
	Provides a method to integrate individual heedfulness with organizational-level assessment	Promotes interorganizational exchange of safety-related reports
	Enables top management to assess the big picture	Pressures from the external environment may influence internal reward system and enhance (or inhibit) reporting
Root cause analysis (RCA)	Fits HRO emphasis on learning from adverse events	Constrained by difficulties of learning from adverse events
	Supports sharing expertise from front lines	Interpreting adverse events, their causes and solutions, can be shaped by political and personal interests
	Works better in organizations with a culture of reliability	Fosters overlooking problems that lack available solutions or ones preferred by management
	Requires a reward system that does not blame or punish those involved in adverse events	Identifying problems can be hindered by complexityand multiple layers of redundancy
	Provides big picture to top management	May lead participants to choose solutions based on ease of implementation

HRT, high reliability theory; NAT, normal accident theory