“Be alert. Keep Calm. Think Clearly. Act Decisively”   – Rule #6 (of the 10 Standard Fire Orders)

ED Sign                     

In the last two posts I have focused on preoccupation with failure and reluctance to simplify, two of the five central principles of high reliability organizing. In this installment we will be turning our attention to Sensitivity to Operations and continue to draw parallels between the emergency department and other HROs. Where the first two are more cerebral this principle strikes at the heart of action-oriented enterprises.

Like those who fight wildfires* we emergency providers are action-oriented. We have the individual and organizational dispoition  well suited to initiate and carry out immediate and aggressive care. Our actions are often tightly coupled (See Introduction) and frequently made without fully developed knowledge of the conditions we face. As such there is always potential risk present.



  • Attentive to the front line.
  • Ensures resources needed to accomplish mission are available.
  • Works hard to break down silos.
  • Encourages communication within and between departments.
  • Attempts to keep focus on the “Big Picture” .
  • Processes a “near miss” not just as a success (I caught the patient before she strangled herself) but as a small failure ((failure to identify and respond to suicide risk).
  • Looks for “small wins” in improving system.


Storm King Memorial On July 2nd 1994 during a year of draught and at a time of low humidity and record high   temperatures, lightning ignited a fire 7 miles west of Glenwood Springs, Colorado. The fire was reported…on July 3rd as being in South Canyon, but later reports placed it near the base of Storm King Mountain. The fire began on a ridge, which was paralleled by two canyons or deep drainages.

[On July 6th ] a dry cold front moved into the fire area…wind and fire activity increased and the fire made several rapid runs with 100 foot flames spreading up the draining on the west side….Within seconds a wall of flame raced up the hill towards the firefighters. Failing to outrun the flames 14 fire fighters perished. The remaining 35 survived by escaping out the east…and deploying their fire shelters. (South Canyon Fire 1994 – Official Report)
That day 14 highly experienced men and women lost their lives when they were trapped by the fire they were fighting. The subsequent investigation found numerous contributors to  their deaths. Some natural (topography, weather conditions, fuel supply, predicted vs. observed behavior) and others man-made:
  • Overly aggressive tactics (direct attack) combined with lack of support and inadequate planned escape route.
  • Warning of high winds not communicated.
  • Discussion but no action on the number of compromised Standing Fire Orders (8 of 10)  and Watchouts (12 of 18) prior to incident.
  • Leadership at fire scene also found lacking.
  • Inadequate briefing of fire crews to dangers, escape routes, safety.
Chaos of ED room


While our work place is not nearly as hazardous as fighting fires in the wilderness the need for a strong commitment to Operations is no different. We must continue to improve the procedures we use to care for patients and foster a culture that puts safe, bedside care at the center. Focus should be on:

  • Communication, communication, communication.
  • Communicating up, down and around.
  • Never assuming other possess what you know.
  • Treating near misses seriously and reporting them.
  • Look for the “small wins”

I love this concept of small wins (producing change without confronting the system directly or aggressively). These “tweaks” not only can improve the immediate environment but also show others in a tangible way that change is possible. I have seen many examples of staff trying something new and it catching on and becoming the preferred method.

Next week (going slightly out of order) I will be covering HRO Principle #5 (Deference to Expertise) and then we will finish up this series with HRO #4 (Commitment to resilience). As always my original lecture continues to be available at:  HRED


* Please note that in comparing our work with those who risk their lives in fighting fire I do so only with the complete and total admiration for those who do what I never could do.