A High Reliability Organization (HRO) is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents are expected due to risk factors and complexity. A NORMAL ACCIDENT or SYSTEM ACCIDENT is an “unanticipated interaction of multiple failures in a complex system. So what does this have to do with emergency medicine?   First a story…. A patient suddenly becomes unresponsive and apneic shortly after extubation following a normal diagnostic workup in the emergency department of a trauma center (not mine). He requires emergent reintubation for a short period of time before he wakes up and begins to breath spontaneously.    The “holes in the swiss cheese” that caused this event were the following:   Hospital policy of properly labeling unmarked meds not routinely followed. Standardized labeling…