Preoccupation with failure in healthcare refers to the need for continuous attention to anomalies that could be symptoms of larger problems in a system. High Reliability Organizations (HROs) that demonstrate a preoccupation with failure strive to detect small, emerging failures because these may be clues to additional failures elsewhere in the system. At its root, preoccupation with failure is a mindset that anticipates and specifies significant mistakes that an organization doesn’t want to make.
Erin Madden, a patient care assistant at Phoenixville Hospital near Philadelphia, made sure that her patient’s bed wheels were locked before transferring her patient into bed. However, the bed moved unexpectedly. Although no harm occurred, the incident lingered in Madden’s mind.
At her unit’s daily safety huddle, she reported her concern about unreliable wheel locks. Her report led to the discovery that more than half of the beds on the unit were unstable, even when the wheel locks were engaged. That discovery led to assessment and repair of wheel locks hospitalwide — and to Erin Madden being recognized in the Pennsylvania Patient Safety Authority’s annual “I Am Patient Safety” contest in 2017.
This anecdote highlights how a preoccupation with failure, a key trait of High Reliability Organizations (HROs), can prevent larger issues. Madden, a frontline caregiver, identified the systemic risks behind a “near miss” with one patient, showcasing the importance of vigilance at all levels of healthcare.
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Preoccupation with failure is not a checklist, although checklists can certainly be part of patient safety. “Preoccupation with failure is a mindset, a way to mindfully organize work, applied by all staff every day on the job,” researchers at Johns Hopkins Armstrong Institute for Patient Safety & Quality wrote in 2017.
The mindset that is preoccupied with failure “look[s] for errors rather than assuming what is in front of them is correct,” the Armstrong researchers wrote, referring specifically to frontline clinicians. “For example, when nurses conduct a high-risk intravenous medication double check, the second nurse should assume the first nurse made a mistake, hunt for it, and correct it, rather than assume the intravenous pump is working or programmed properly and the medication is right.”
This thought process – “something here might harm my patient, and I’m going to find it and fix it” – exemplifies preoccupation with failure. However, this mindset does not come naturally. It is a habit that must be taught and reinforced. The Armstrong researchers suggested adding preoccupation with failure to classroom training for health care providers. “For example, in a simulation laboratory students or physicians could identify errors with a mediation pump or a ventilator set up,” helping to reinforce the mindset during clinical rotations.
In the healthcare setting, unit-level managers can continually reinforce the preoccupation with failure during daily huddles or briefings. “Managers can also ask frontline staff that thought-provoking question, how will the next patient be harmed, and use their responses to proactively identify and mitigate those risks,” the Armstrong researchers suggested. These discussions help strengthen the culture of preoccupation with failure across the organization.
Spotting and fixing safety risks before they do harm is not enough. Reporting these near misses or good catches should be seen by frontline caregivers “as equally important in the scheme of event reporting.” Why? Because more near misses reported results in fewer serious events in which patients are actually harmed – a key goal of every High-Reliability Organization (HRO).
Just like preoccupation with failure, reporting good catches must be taught and incentivized. Multiple studies have confirmed that providers report more good catches when they are encouraged to. For instance, the American Academy of Family Physicians National Research Network invited clinicians and staff in 10 family medicine clinics to report errors during a 10-week study. Five days during the study were designated for reporting every error they observed. Ultimately, 37% of the reports were made during the five intensive reporting days.
This holds true within individual healthcare organizations as well. The Pennsylvania Patient Safety Authority tracked reporting in four hospitals that had good catch reporting systems in place. Between 2005 and 2016, the number of good catches reported by the hospitals increased by more than 60% (from 33,777 in 2006 to 54,472 in 2016) while the number of serious events decreased by 14%. For a deeper dive into this concept, check out our guide on sensitivity to operations, another key HRO trait that helps mitigate risks.
As the defective wheel lock example shows, the preoccupation with failure mindset and reporting must be followed up with managerial action. This often includes a formal data collection process, such as American Data Network’s Patient Safety Event Reporting Application, which helps track and analyze incidents. Additionally, fostering a virtuous cycle of recognition encourages more staff alertness and reporting, further reducing harmful events.
Some healthcare settings have used internal newsletters to recognize good catches, especially those that have led to systemic improvements. Greater Baltimore Medical Center, for instance, used its MD Today publication to highlight a near miss that resulted in epinephrine and ephedrine no longer being stored next to each other in medication storage areas, prompting changes to prevent future errors.
Another facility that participated in a 47-hospital Good Catch Initiative led by the American Data Network Patient Safety Organization (ADNPSO) incentivized reporting through recognition programs, offering extra vacation days to quarterly award winners. Recognizing good catches not only reinforces the preoccupation with failure mindset but also encourages staff to remain vigilant.
While there’s no single roadmap to becoming preoccupied with failure, a successful focus on failure often starts with obsessive data scrutiny.
The following tactics fall into three main categories:
To enhance your organization’s preoccupation with failure and start answering these critical questions, explore the 7 free tools and resources below.
Cultivating preoccupation with failure is essential for healthcare organizations striving to achieve high reliability. By proactively identifying, reporting, and acting on near misses and systemic risks, teams can prevent small issues from escalating into serious harm. This mindset requires a combination of data-driven insights, continuous staff engagement, and leadership support to foster a safety-focused culture.
Utilizing tools like event reporting calculators, gap analyses, and good catch campaigns, organizations can strengthen their vigilance and improve patient outcomes. With a strong culture of preoccupation with failure, healthcare facilities can drive lasting improvements in safety and quality, positioning themselves as leaders in patient care.
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