Most risk management activity in the healthcare sector is retrospective, based on learning from experience. This is feasible where the risks are routine, but emergency operations plans (EOP) guide the response to events that are both high risk and rare. Under these circumstances, it is important to get the response right the first time, but learning from experience is usually not an option. This case study presents the rationale for taking a proactive approach to improving healthcare organizations' EOP. It demonstrates how the Prospective Hazard Analysis (PHA) Toolkit can drive organizational learning and argues that this toolkit may lead to more efficient improvement than drills and exercises.@en