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Building high reliable healthcare systems to reduce avoidable patient harm is a global priority. However, there is variability in the application and understanding of the previously identified High Reliability Organization (HRO) principles to make improvements. We describe specific organizational activities exemplifying the five HRO principles during the planning and go-live periods of the new Electronic Health Record (EHR) system at a multi-site academic health sciences centre in Ontario, Canada. Further, we describe a case example where all five HRO principles were exemplified during EHR implementation. Overall, 23 activities exemplifying organizational anticipation and resiliency were identified. Of the 23 activities, 12 occurred during the preparing for go-live and 11 activities occurred during the go-live periods. This paper demonstrates how HRO principles can be used in healthcare to detect and adapt to patient safety threats, in order to prevent avoidable patient harm during large scale change.

In an era of significant human and fiscal constraints, hospitals increasingly rely on industry representatives to fill gaps related to practice-based education. Given their dual sales and support functions, the extent to which education and support functions are, or ought to be, fulfilled by industry representatives is unclear. We conducted an interpretive qualitative study at a large, academic medical centre in Ontario, Canada, during 2021-2022, interviewing 36 participants across the organization with direct and varied experiences with industry-delivered education. We found that ongoing fiscal and human resource challenges prompted hospital leaders to outsource practice-based education to industry representatives, which created an expanded role for industry beyond initial product rollouts. Outsourcing, however, generated downstream costs to the organization and undermined the goals of practice-based education. To attract and retain clinicians, participants advocated for re-investment in practice-based education in-house, with a limited and supervised role for industry representatives.

D uring the COVID-19 pandemic, many hospitals were forced to put nonessential surgeries on hold, restrict visitors and other nonessential personnel, and create new processes to screen and control entry into the hospital and, in particular, clinical spaces. In all these, there was one category of visitor that required special consideration-medical device representatives who provide product-related education and support.COVID-19 restrictions within hospitals raised important questions about whether and in which cases medical device representatives are "essential" and to what extent hospitals and nurses have become dependent on their services. The pandemic prompted important questions about the benefits and risks of having medical device representatives in clinical spaces, which include issues related to trust and informed consent, infection risk, efficiency of surgeries, confidentiality and privacy, and commercial influence (Grundy et al., 2018). The pandemic also raised questions about whether and to what extent perioperative teams are dependent on medical device representatives and what this might mean for safe, quality, ethical, and cost-effective care. INDUSTRY REPRESENTATIVES AS EDUCATORSIndustry representatives are present in hospitals on a daily basis, in operating rooms, cardiac catheterization laboratories, and patient care units and are often available remotely 24/7 (Grundy et al., 2018). Surgeons, nurses, and administrators generally consider their expertise to be essential to product use given the increasing variety and complexity of medical technologies, the rapid introduction of new products, and the funding pressures faced by hospitals.Activities of industry representatives include being on call and/or physically present to provide technical guidance or troubleshooting issues with implants; guiding nursing staff through the selection of instruments and helping to pace surgical procedures efficiently; advising on tailoring equipment settings to individual patients; providing in-house training to staff on the use of new products such as glucometers or intravenous pumps; and fulfilling, curating, or sponsoring ongoing education needs related to wound care, surgical