Relational-reliability on the move: a review of a Busby and Iszatt-White paper while thinking about medication errors and health IT implementations

‘[o]rganizations transform, rather than solve, reliability problems’ [1][p77].

Busby and Iszatt-White [1] build on the theory of collective mindfulness in HROs [2] to propose a relational view of reliability that calls for a mindfulness approach to understanding reliability failures. Theirs is a study of a company delivering construction and management of highways, with a focus on this organisation’s efforts to achieve safety of its workers (e.g. not being hit by cars while fixing a motorway or injured by excessive chain saw vibration). Their analysis is based on data they collected over 20 days of observations and seventeen interviews across two of the company sites. In reflecting on their findings, I summarise their concepts and transpose them to the world of medication safety and hospital technology implementations.

Relational Reliability

Reliability in high-risk organisations (HROs) is usually understood both as the absence of organisational accidents or failures (an outcome), and as an ongoing organisational achievement [*]. As shown in studies of HROs, achieving reliability is ‘difficult and needs deliberate, assiduous effort’ [1][p70]. Building on reliability in HROs, Busby and Iszatt-White extend reliability as the foundation for the life of any organisation, which is ‘entities becoming able to depend on others and becoming able to be depended upon’ [p69] without failures. They thus highlight the need to consider both ‘actors doing the relying’, and ‘those being relied upon’ and thus introduce a relational view of reliability (indeed, in their view, the meaning of reliability ‘is produced by a relationship’ [p71]).

In their study of the motorway company, they found that people had different and multiple understandings of reliability and there was a ‘transformation between different kinds of understanding’ [p72]. More specifically, they identified four types of overlapping understandings, which they explain as follows:

  • Conformative understandings [of reliability], emphasizing an actor relying on some other actor to conform to standards, norms, conventions or rules.
  • Performative understandings, emphasizing an actor relying on some other to perform or achieve some substantive action or outcome.
  • Adaptive understandings, emphasizing an actor relying on some other to reform, fit or adapt resources like knowledge and rules to some circumstance.
  • Informative understandings, emphasizing an actor relying on some other to inform, communicate, or reveal what that other can achieve or accomplish’ [p73]

Examples of conformative understandings of reliability include managers relying on workers to follow rules, or clients relying on the company to conform to health and safety law. Conformative understandings of reliability highlights how there may be a difference between ‘reliability as achieving an intrinsic good and reliability as conforming to a mere expectation, norm or rule’ [p73]. The latter has consequences in terms of litigation, but in terms of achieving ‘intrinsic good’ (safety) in the organisation, participants perceived that conformative reliability is ‘limited or flawed’’, ‘constraining and inflexible’ [p73].

Contrary to confirmative reliability, performative understandings of reliability is about substantive action being taken, or outcome achieved by the people relied-on. Examples include managers relying on workers self-assessing when it’s safe ‘to go over time’ and keep on working, or workers recognising and then removing hazards by using checklists. Attempting to achieve this type of reliability involved training, reminders, ‘efforts of acculturation’, and efforts to create a safety culture [p74]. It also involved workers assessing trade-offs and making choices between productivity and safety (which reminds me of the ETTO principle [4]).  

Adaptive understanding of reliability ‘is about suiting, adapting, or fitting some circumstance’ [p75]. It is about relying that the appropriate action has being taken by the person relied-on, through adapting to – and being mindful of– what is required by the specific context. Examples include using the rules of a generic risk assessment ‘as a basis for adapting their actions to specific circumstances’ [p75]’– such as noticing that ‘[…] slabs look a bit covered in moss, they are a bit slippy’ posing risks for chain saw work [p75, citing a depot supervisor]. Adaptive understandings of reliability co-exist with other understandings of reliability, but by making a separate category, the authors emphasize ‘an important kind of relying in which we avoid specifying expectations and instead rely on actors ‘common sense’ and ‘situation awareness’ and their capacities to ‘act appropriately’ and ‘read the lie of the land’’ [p75, emphasis added]. 

Finally, informative understandings of reliability is about relying on others to be ‘informative’ – for example about what they are able to accomplish. It is not only about performance, but about ‘transparency, legibility, or honesty’ [p76]. Examples included ‘a supervisor […] [relying] on people doing those things which were known to do – and the difficulties of remembering not to rely on new people for the same things’ [p76]. It seems that this category would apply to any distributed work that relies on others providing the right information (e.g., in the case of medication, a correct, legible, prescription). The authors stress how this type of reliability ‘shows the aptness of a relational view of reliability in the context of collective activity where information is as important as outcome’ [p76].

While presenting these different categories of reliability, Busby and Iszatt-White eventually discard them, if only because of the limitations of the typology they propose – which may not be exhaustive or exclusive [p76]. They are also ‘so interrelated that any given account is unlikely to express just one of them’ [p76] [for example, ‘the success of […] adaptation is judged on conformative or performative grounds’ -p76]. The categories ‘are less significant than the way they are related to each other’ [p72]. The important point is that there are different kinds of understanding of reliability produced in organisations and that these understandings are relational between a ‘relying subject’ and ‘a relied-on object’.

Reliability, relational shifts in healthcare

I believe anyone working in hospital would recognise the four types of reliability explained above. A myriad of rules, guidelines or standards are put in place to achieve reliable (and safe) medication use, and managers rely on front-line clinicians to apply them (conformative reliability/reliance), and applying the rules is important, for example in view of litigation. But everyone also knows that without substantive actions (performative), fit to the specifics of the patient and circumstances (adaptive), rules are not sufficient on their own to achieve safety, and efforts are thus directed towards ‘empowering’ clinicians (e.g. through training, or decision support, so that, for example, they will make a correct choice of medications for the patient) and foster a safety culture.

People in hospital would probably also mostly agree with the authors that ‘When a particular relationship is in the foreground of conversation [e.g. planning for ePrescribing implementation, versus dealing with a specific patient medications], the understanding [of reliability] most relevant to that relationship is most likely to be operative, and the organization does not particularly resolve or collapse these different understandings’ [p76].

A relational reliability reading of a hospital in the UK introducing ePrescribing (experiences reported in [5])…. In oncology the protocol rule must be followed ‘to start folic acid at a certain time after the methotrexate’ has been given, but doctors do not have enough information to be able to make the prescription comply (conformative reliability), i.e. ‘when they prescribe the folic acid on ePrescribing they don’t know what time the methotrexate is going to be started so they can’t prescribe it with a certain time’.  Relying on conformative reliability did not achieve safety in this context – ‘they were finding that it wasn’t happening’. Thus, a workaround was put in place that enabled to achieve performative reliability (substantial reliability) by shifting responsibility for completing the prescription to nurses and allowing them thus to adapt the prescription to the actual times of administration for the specific patient – ‘the nurses have to be given prescribing rights [empowerment?] for that drug so that they can add the time or amend the time when they know what time it needs to be given’ ([5] citing Chief pharmacist, Post-implementation, Site C Standalone).

Busby and Iszatt-White [1] argue that ‘[o]rganizations transform, rather than solve, reliability problems’ [p77]. ‘There is always some network of relationships that transform reliability problems in certain relationships into reliability problems in other relationships’ [p77]. This may happen with the introduction of new technology. For example, the activity of restocking medications in a clinical ward for timely patient administration has a nurse-pharmacy relying-relied-on relationship; if then a barcoded automated cabinet is placed in the ward, providing real-time data on stock to pharmacy, then pharmacy staff does not have to rely on nurses to request items on time, but both nurses and pharmacists are now relying on the technology to work as intended. The reliability problem has shifted to the technology. Thus, as Busby and Iszatt-White explain, in organisations ‘this transformation keeps unfolding until – from the perspective of any one of the relevant relationship – the reliability problem it experiences is resolved, satisfactorily or not’ [p77].

Busby [6] further explores this idea of transformation in relation to risk – that ‘risks are transformed not solved by attending to them’ [6][p73]. This is especially so, for example, in introducing new technology – aimed to solve a risk problem (e.g. risk of drug-drug interaction in prescribing), ‘only to produce another’ [6][p74] (e.g. risk of alert fatigue). In this light, risk is recursive, and ‘needs to be thought as a process that unfolds over time’ [p75].  

Failings in relational reliability (and mindfulness)

From a relational reliability perspective, issues with reliability in organisations arise on two levels; first, relying may not be appropriate ‘in the context of a particular relationship’ [p77]; second, relying may not be ‘coherent’ across a relationships network. Busby and Iszatt-White [1] note that the first – i.e. ‘unreasonable relying’ –  is ‘part of the common diagnosis of events like the Challenger disaster’ [1][p78]. This may be true also in the investigation of medication safety events (e.g. [7]).

In the organizing of the medication process, each step (e.g. prescribing, dispensing, administration) depends on the previous ones to be carried out reliably and each step ‘foresees’ the next ones to be carried out reliably. It could be argues that reliability at each step is reciprocal and of the four kinds, i.e.: clinicians believing others in the medication process will conform to standards, norms, conventions or rules (conformative) and will act on those rules in the interest of safety (performative); clinicians believing others in the medication process will adapt the rules to the patient circumstances (adaptive); they will inform others in the process of what has been done, and whether they are not able, or have been able, to perform (informative). The process includes a number of checks (built-in redundancy). However, how the checks are performed (and whether they are effective at noticing errors) may depend on relational relying-on/relied upon between clinicians involved in a patient medication process. Would these relations be purely professional-based (on roles, e.g. nurses with doctors, nurses with nurses) or rather personal (based on familiarity and time spent working together)? Clinicians form ‘opinions and judgements’ about others capacities with medications through working together (like the pharmacists with junior doctors, about their prescribing capacities [8]). A relational view of reliability requires ‘an appreciation of what the present nature of a relationship implies in terms of who is doing the relying, who is being relied on, what they are being relied on for; whether it is somehow proper, what the standard of achievement is, and how it is to be achieved’ [p77]. This appreciation is part of being mindful – i.e. sensitive to context [9, 10] and not over reliant on ‘categories and distinctions drawn in the past’ [10] – and applies to both ‘actors doing the relying, as well as those being relied upon’ [1][p78]. It is also about being collectively mindful, in the sense of ‘sensing the current patterns of relying and reliability’ [p78] in the organisation.


[*] There is a debate and extensive literature on the definition of HROs, but for now left outside the scope of this post. Also to be precise, reliability is not equivalent to safety (a system, or its components, can be reliable and unsafe [3]).


[1]        Busby, J. and M. Iszatt-White, The Relational Aspect to High Reliability Organization. Journal of Contingencies and Crisis Management, 2014. 22(2): p. 69-80.

[2]        Weick, K.E., K.M. Sutcliffe, and D. Obstfeld, Organizing for High Reliability: Processes of Collective Mindfulness. Research in Organizational Behavior, 1999(21): p. 81-123.

[3]        Leveson, N., A new accident model for engineering safer systems. Safety Science, 2004. 42(4): p. 237-270.

[4]        Hollnagel, E., The ETTO principle: efficiency-thoroughness trade-off: why things that go right sometimes go wrong. 2009, UK: Ashgate.

[5]        Mozaffar, H., et al., Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study. BMJ Quality & Safety, 2017. 26(9): p. 722-733.

[6]        Busby, J., Why risk is recursive and what this entails, in Routledge Handbook of Risk Studies A. Burgess, A. Alemanno, and J.O. Zinn, Editors. 2016, Routledge. p. 73-80.

[7]        Toft, B., External inquiry into the adverse incident that occurred at Queen’s Medical Centre, Nottingham, 4th January 2001. 2001, London, UK: Department of Health.

[8]        Noble, C., et al., Developing junior doctors’ prescribing practices through collaborative practice: Sustaining and transforming the practice of communities. Journal of Interprofessional Care, 2017. 31(2): p. 263-272.

[9]      Langer, E.J., Mindfulness forward and back. The Wiley Blackwell Handbook of Mindfulness, 2014: p. 7-20.

[10]      Langer, E.J., Matters of mind: Mindfulness/mindlessness in perspective. Consciousness and Cognition, 1992. 1(3): p. 289-305.

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