This study investigates how a selected regional public healthcaresystem (RPHS) in Sweden prepared for and responded during thepre-crisis phase preceding the COVID-19 pandemic. Employinga qualitative methodology, eight semi-structured interviews wereconducted with employees from the RPHS, and the data were ana-lyzed using thematic analysis. Six key themes emerged from theanalysis: understanding the situation, preparations, applying the pandemic preparedness plan, organizational changes, challenges,and co-operation. A significant contribution of this study is the iden-tification of three distinct sub-phases within the pre-crisis phase: (1)actions undertaken preparing for an unknown future pandemic, (2)precautionary measures initiated following the emergence of initialreports of COVID-19, and (3) escalated preparations when a localoutbreak became inevitable. The findings were further contextual-ized through the theoretical lenses of High Reliability Organizations(HRO) and Resilience Engineering (RE), offering deeper insightsinto the underlying processes of the pre-crisis phase. For instance,the HRO principle of reluctance to simplify was reflected in thetheme understanding the situation, where the RPHS’s initial un-derestimation of the crisis delayed critical organizational changes,such as the establishment of the regional medical command and control team for disaster response (RMC2). Similarly, the RE con-cept of anticipating potential challenges was evident in the themesof preparations and challenges, highlighting how the RPHS antici-pated the need for specialized competencies but failed to sufficientlypredict the demand for personal protective equipment. This papercontributes to the area of cognitive ergonomics by analyzing howhealthcare and crisis management professionals perceived, antici-pated, and responded to an unfolding crisis (i.e., the upcoming localoutbreak of COVID-19). Using empirical data and theoretical lensesfrom HRO and RE, it is revealed how cognitive processes, suchas sensemaking, attention allocation, and decision-making underuncertainty, shaped outcomes. These insights can inform the de-sign of future systems, interfaces, and training aimed at supportingcognitive work in complex, high-stakes environments.