EMS & high reliability organizing. Achieving safety & reliability in the dynamic, high-risk environment

Enactment describes how we engage the situation to make sense of it. But by our engagement, we also change the situation. Our presence, alone, will change the situation. At times, we may fail to act. Here, we are at risk of interpreting this as a sense of personal "limitation" in what we can do. This will inhibit us in engaging in other incidents. Rather, we should understand that while we may often fail after engaging, acting is part of performing in uncertainty. In EMS, the system, as it's set up, can lead people to fail to act. For reasons specific to a system, the EMT or paramedic may not act for fear of doing something wrong. This failure to act reinforces the limitations one feels. When you avoid acting, you don't learn. By avoiding testing ourselves, we conclude that constraints exist. This is contrary to the historical approach public safety and EMS personnel use to learn. In the past, it was accepted that we learn what works through action. We also perceive, or sensemake, through interaction with the environment. We watch for responsiveness to our actions, such as cooperation from bystanders vs. defiance. However, this is influenced by how we approach the scene. One EMS provider may obtain cooperation while another experiences defiance. We bracket this information by placing it in context. This interaction is difficult to communicate to those not present at the incident, because they don't know when one "story" begins and when another leaves off. HROs have developed in organizations that adapted to time constraints in uncertain and hazardous environments. There, lessons were actually learned through the blood of live-or-die situations. Academics have codified these principles and concepts that are accessible to EMS caregivers. EMS can benefit from the principles and concepts of HRO through improved performance by individuals and stronger organizations.