Final paper published.pdf (336.52 kB)
Download file

Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare.

Download (336.52 kB)
journal contribution
posted on 19.01.2018, 11:33 by Elisa G. Liberati, Mohammad Farhad Peerally, Mary Dixon-Woods
Objective: Though healthcare is often exhorted to learn from 'high-reliability' industries, adopting tools and techniques from those sectors may not be straightforward. We sought to examine the hierarchies of risk controls approach, used in high-risk industries to rank interventions according to supposed effectiveness in reducing risk, and widely advocated as appropriate for healthcare. Design: Classification of risk controls proposed by clinical teams following proactive detection of hazards in their clinical systems. Classification was based on a widely used hierarchy of controls developed by the US National Institute for Occupational Safety and Health (NIOSH). Setting and participants: A range of clinical settings in four English NHS hospitals. Results: The four clinical teams in our study planned a total of 42 risk controls aimed at addressing safety hazards. Most (n = 35) could be classed as administrative controls, thus qualifying among the weakest type of interventions according to the HoC approach. Six risk controls qualified as 'engineering' controls, i.e. the intermediate level of the hierarchy. Only risk control qualified as 'substitution', classified as the strongest type of intervention by the HoC. Conclusions: Many risk controls introduced by clinical teams may cluster towards the apparently weaker end of an established hierarchy of controls. Less clear is whether the HoC approach as currently formulated is useful for the specifics of healthcare. Valuable opportunities for safety improvement may be lost if inappropriate hierarchical models are used to guide the selection of patient safety improvement interventions. Though learning from other industries may be useful, caution is needed.


This work was supported by the Health Foundation, charity number 286967, and by Mary Dixon-Woods' Wellcome Trust Senior Investigator Award (WT097899).



International Journal for Quality in Health Care, 2017

Author affiliation

/Organisation/COLLEGE OF LIFE SCIENCES/School of Medicine/Department of Health Sciences


VoR (Version of Record)

Published in

International Journal for Quality in Health Care


Oxford University Press (OUP) for International Society for Quality in Health Care





Acceptance date


Copyright date


Available date


Publisher version


Supplementary material is available at International Journal for Quality in Health Care online.



Usage metrics