Background: Patient handling injuries (PHIs) are one of the leading causes of work-related injuries among healthcare workers. PHIs occur from activities of turning, repositioning, and transferring patients. Organizational approaches to mitigate PHIs include the implementation of Safe Patient Handling and Mobilization (SPHM) programs, including proper patient handling education, lift equipment use, and policy implementation. High Reliability Organizations (HROs) are another organizational approach to improve workplace safety and adhere to the principles of preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise. In healthcare, HRO research has centered mainly on patient safety outcomes, with limited exploration of its impact on staff safety, such as PHI rates.Purpose: The specific aims of the study were to (1) identify and synthesize the current state of evidence of the impact of HRO on safety outcomes in healthcare, (2) examine the relationship between SPHM program compliance levels and direct care staff’s PHI rates in Veterans Health Administration (VHA) facilities, and (3) examine the relationship between HRO implementation (HRO climate and duration) and direct care staff’s PHI rates in VHA facilities. Methods: The study conducted a scoping review to synthesize the literature on HRO implementation and the safety outcomes of patients and staff (Aim 1). For Aims 2 and 3, the study analyzed cross-sectional data from the VHA’s Annual SPHM Survey in 2023 and 2024 (SPHM performance criteria, PHI rates, facility characteristics), and the HRO Office Surveys in 2024 (HRO Module Questionnaire and facilities’ HRO duration). The study sample included 124 Veterans Health Administration (VHA) facilities across the United States. A negative binomial regression model was used to analyze the relationship between SPHM program compliance, HRO implementation, and PHI rates. The multivariable models were adjusted for the following facility characteristics: facility type (e.g., acute care, long-term care), facility size by the number of direct care staff, bed capacity, facility complexity in terms of patient acuity, staff-to-patient ratio, and ceiling lift coverage. Results: The scoping review included nine studies. Most studies focused on patient safety outcomes and staff perception of patient safety. Only one study pertained to staff outcomes, primarily psychological safety and job satisfaction. In the analysis of VHA survey data, the SPHM Compliance Index was positively associated with PHI rates after controlling for staff-to-patient ratio (β = 0.037, p = 0.04); but when the models added other covariates, SPHM Compliance Index was no longer significant for PHI rate. HRO implementation (HRO climate and duration) did not have a significant relationship with PHI rates. Among facility characteristics, staff-to-patient ratio, facility type, and facility size showed significant associations with PHI rate. Staff-to-patient ratio was negatively associated with PHI rates (β = -0.002, p <.05). PHI rates were significantly lower in ambulatory care facilities (β = -1.114, p = .01) compared to mainly long-term care facilities. Also, PHI rates were lower in with facilities with 1,000-1,999 direct care staff (β = -0.543, p <.01) and facilities with ≥2,000 direct care staff (β = -0.517, p <.05) compared to small-sized facilities. Higher PHI rates were associated with greater ceiling lift coverage (β = 0.006, p = 0.03) and high facility complexity working in level 1a (β = 0.806, p = 0.04) compared to level 3 or least complex facility. Conclusion: For the SPHM program, while this study found some mixed results in different models, SPHM program compliance showed a significant association with PHI rates when staff-to-patient ratio was accounted for. However, their positive relationship (higher SPHM programs compliance associated with higher PHI rate) was unexpected; this finding may be explained by program’s promotion of active surveillance—leading to higher recorded PHI or by reverse causation, and requires further research to validate the finding. Additionally, For HRO implementation, this study did not find evidence supporting the significant effect on PHI rate, and this finding may be explained by HRO program’s implementation mainly integrated towards patient safety operations. The study offers insights into the impact of organizational programs for workplace safety and highlights the important facility characteristics associated with PHI rates among direct care staff, such as staff-to-patient ratio, facility type, facility size,, and ceiling lift coverage.