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High Reliability Organizations (HROs) are complex systems in which many accidents and adverse events that could occur within those systems or at the interfaces with other systems are actually avoided or prevented. Many organizations in high-risk industries have successfully implemented HRO approaches. In recent years, initiatives have been undertaken aimed at transforming hospitals into HROs. Actually, despite some improvements, these initiatives have not shown the expected results. In this paper, we discuss the possible reasons for such outcomes. We will show that, when compared with traditional HROs, hospitals are undoubtedly high-risk organizations, but have specificities and experience systemic socio-organizational barriers that make them difficult to transform into HROs., (2010. Published by Elsevier Ltd.)