High Reliability Organizations and Surgical Microsystems: Re-engineering Surgical Care Juan A. Sanchez, MD, MPA a,b, *, Paul R. Barach, MD, MPH c I would not give a fig for the simplicity this side of complexity, but I would give my life for the simplicity on the other side of complexity. —Oliver Wendell Holmes Jr 1 THE HIGH RELIABILITY ORGANIZATION The surgical space, by its nature, is a high-risk environment where hazards lurk around every corner and for every patient. The patients who come to surgery are generally among the sickest and at more advanced stages of disease. The very act of treatment involves interventions that are often considerably invasive with vigorous and unpre- dictable physiologic responses. The level of complexity, both in task-oriented and cognitive demands, results in a dynamic, unforgiving environment that can magnify the consequences of even small lapses and errors. Other complex sociotechnical systems, which operate in similar environments, have been able to redesign their operations such that they consistently perform at high levels of safety with reliable outcomes. These high reliability organizations (HROs) have characteristics that parallel many features of the surgical environment, including the use of complex technologies, a fast-paced tempo of operations, and a high level of risk, yet they manifest spectacularly low error rates. HROs are required to respond to a wide variety of situations under changing environmental conditions in a reliable and a Department of Surgery, Saint Mary’s Hospital, 56 Franklin Street, Waterbury, CT 06706, USA b University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030, USA c Utrecht Medical Centre, Utrech, The Netherlands * Corresponding author. Department of Surgery, Saint Mary’s Hospital, 56 Franklin Street, Waterbury, CT 06706. E-mail address: Juan.Sanchez@STMH.ORG KEYWORDS  High reliability  Clinical microsystems  Teams  Patient safety  Safe culture  Normal accident theory Surg Clin N Am 92 (2012) 1–14 doi:10.1016/j.suc.2011.12.005 surgical.theclinics.com 0039-6109/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.