Building a Critical Incident Management Program in a Transfer Center Setting

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A critical incident (CI), by definition, is any situation that causes psychological distress. Examples of CIs in healthcare include, but are not limited to, catastrophic events, patient deaths, medical errors, medical emergencies, near misses, and physical harm. In healthcare, CIs are common occurrence. The collateral, negative impacts of CIs on patients/families, the physical, emotional, and professional well-being of healthcare professionals, and healthcare organizations are complex and multidimensional, making it imperative for health care organizations to have comprehensive safety programs in place. The transfer center is one department of a for profit organization, owned by a midwestern nonprofit hospital network, comprised of a team of RNs and ancillary staff that work remotely and facilitate patient transfers in and out of acute care facilities. No formal patient safety policy or evidence-based critical incident management program specific to the transfer center currently exists. The purpose of this project is to create an evidence-based critical incident management program proposal in a transfer center setting. A literature review was conducted to inform the proposal and explore the concept of safety management in complex systems, define the term critical incident in healthcare, investigate the impact critical incidents have on registered nurses and the healthcare system, discover how leadership style and workplace culture impact patient safety and staff response to critical incidents, identify the types of critical incident management interventions used in the healthcare industry today as well as the outcomes and barriers, and address additional considerations for a remote work setting. Six themes emerged from the literature which were used along with concepts from Maslow’s hierarchy of needs, transformational leadership theory, expert panel guidance, and existing program models to propose a three-tiered CI management program in a transfer center setting (CIMP-TC).