CASE STUDY: CRISIS/INCIDENTS

MANAGEMENT

Poe,Keannue Pangatungan

BSCRIM 4107
Critical incident reporting and learning
Manahan (2010) the success of incident reporting in
improving safety, although obvious in aviation and other
high-risk industries, is yet to be seen in health-care
systems. An incident reporting system which would
improve patient safety would allow front-end clinicians to
have easy access for reporting an incident with an
understanding that their report will be handled in a non-
punitive manner, and that it will lead to enhanced
learning regarding the causation of the incident and
systemic changes which will prevent it from recurring. At
present, significant problems remain with local and
national incident reporting systems. These include fear of
punitive action, poor safety culture in an organization,
lack of understanding among clinicians about what should
be reported, lack of awareness of how the reported
incidents will be analysed, and how will the reports
ultimately lead to changes which will improve patient
safety. In particular, lack of systematic analysis of the
reports and feedback directly to the clinicians are seen as
major barriers to clinical engagement. In this review,
robust systematic methodology of analysing incidents is
discussed. This methodology is based on human factors
model, and the learning paradigm which emphasizes
significant shift from traditional judicial approach to
understanding how ‘latent errors’ may play a role in a
chain of events which can set up an ‘active error’ to
occur. Feedback directly to the clinicians is extremely
important for keeping them ‘in the loop’ for their
continued engagement, and it should target different
levels of analyses. In addition to high-level information
on the types of incidents, the feedback should
incorporate results of the analyses of active and latent
factors. Finally, it should inform what actions, and at
what level/stage, have been taken in response to the
reported incidents. For this, local and national systems
will be required to work in close cooperation, so that the
lessons can be learnt and actions taken within an
organization, and across organizations. In the UK, a
recently introduced speciality-specific incident reporting
system for anaesthesia aims to incorporate the elements
of successful reporting system, as presented in this
review, to achieve enhanced clinical engagement and
improved patient safety.
Restraint and critical incident reduction
following introduction of the Neurosequential
Model of Therapeutics (NMT)
Residential Treatment for Children & Youth 35 (1), 2-23,
2018

HAMBRICK (2018) Children with developmental trauma

are at risk for severe and complex behavioral problems,
often requiring long-term residential and day treatment.
The Neurosequential Model of Therapeutics (NMT) is a
developmentally sensitive approach to clinical work with
a capacity-building component focusing on attachment,
the impact of maltreatment and trauma, and emerging
concepts in developmental psychology, neuroscience and
traumatology. Research has demonstrated its
effectiveness with trauma-exposed populations. NMT
training may help providers working with trauma-
exposed youth prevent critical incidents and reduce
restraints. Restraint and critical incident data were
obtained from 10 organizations providing residential
and/or day-treatment services following exposure to, or
certification in, the NMT. Data from the Pre-NMT
Introduction period through to the Maintenance phase of
NMT Certification were used to examine changes in
restraints and critical incidents across phases of NMT
exposure/certification. Multilevel logistic regression
models suggested that NMT exposure and/or certification
was associated with significant reductions in restraints
and critical incidents. Reductions were sustained
throughout the Maintenance phase. Estimates of potential
staff hour and financial savings associated with these
reductions are discussed. Implementation of the NMT in
residential and day-treatment settings may result in
staff, behavioral health provider, and organization-level
changes that reduce critical incidents and restraint use.
THE BENEFITS OF COVID-19 FOR CRISIS
MANAGEMENT IN
AMERICAN CHURCHES
Vesely (2022)

Abstract: American churches are not prepared when

facing crises. Although many successful for-

profit businesses have adopted the ideas of crisis

management and written plans for emergencies,

many churches are still struggling to think beyond just

crisis response. This study aims to

understand if there are different ways church leaders

approach crises and emergency planning

depending on cultural, organizational, and urban-vs-rural

differences. For this research, the

COVID-19 pandemic provides a control to better

understand if and how churches respond to

crises.

The data for this project was collected by means of a

survey that was sent to church leaders

associated with the American Baptist Association. This

association of churches was chosen due

to the freedom of individual choice each church and its

leader have to best fit in with the
community is serves. The results showed that there were
differences depending on a leader’s age,

congregation size, whether it was rural or urban, and the

degree of conservativeness. The results

also showed that churches cannot accurately explain

what constitutes as a crisis. These results

suggest that churches should be more informed with best

practices to write effective crisis

management plans.
The Critical Incident Technique: An
Innovative Qualitative Method of Research

Woolsey (2011)

The critical incident technique is an exploratory

qualitative method of research that has been shown both
reliable and valid in generating a comprehensive and
detailed description of a content domain. After being
used widely in industrial psychology during the 1950's,
the technique fell into diverse and is only now enjoying a
renaissance. The critical incident technique basically
consists of asking eyewitness observers for factual
accounts of behavior’s (their own or others') which
significantly contribute to a specified outcome. The
emphasis is on incidents (things which actually happened
and were directly observed) which are critical (things
which significantly affected the outcome). This paper tells
how to do a critical incident study, using illustrations
from the author's and others' research. The many and
varied applications of the technique are indicated. These
uses range from criterion development and test
construction to foundational work and theory
development. It is concluded that the critical incident
technique should contribute significantly to the
development of a unique methodology for the discipline
of counselling.
In the eye of a quiet storm: A critical incident
study on the quarantine experience during
the coronavirus pandemic
Durosini (2021)

In 2020, the COVID-19 appeared in Italy with an

exponential transmission capacity and serious
consequences for the whole population. To counter the
spread of the virus, the Italian government has adopted
an extensive lockdown, forcing citizens to stay at home
and avoid social contact. The COVID-19 quarantine
represents a unique phenomenon in the recent centuries,
and its long-term consequences on people’s lives and
mental health are still to be understood. This study aimed
to explore significant experiences of people who did not
contract the virus, yet experienced the quarantine as a
potentially stressful condition
Decision inertia in critical incidents

Nicola Power, Laurence Alison

European Psychologist (2018)

When presented with competing options, critical incident decision
makers often struggle to commit to a choice (in particular when
all options appear to yield negative consequences). Despite being
motivated to take action in disasters, terrorism, major
investigations, and complex political interventions, decision
makers can become inert, looping between phases of situation
assessment, option generation, and option evaluation. This
“looping” is functionally redundant when it persists until they
have lost the opportunity to take action. We define this as
“decision inertia”: the result of a process of (redundant)
deliberation over possible options and in the absence of any
further useful information. In the context of critical incidents
(political, security, military, law enforcement) we have discovered
that rather than disengaging and avoiding difficult choices,
decision makers are acutely aware of the negative consequences
that might arise if they failed to decide (ie, the incident would
escalate). The sensitization to possible future outcomes leads to
intense deliberation over possible choices and their consequences
and, ultimately, can result in a failure to take any action in time
(or at all). We (i) discuss decision inertia as a novel psychological
process of redundant deliberation during crises;(ii) define the
concept and discuss the emerging studies in support of our
tentative hypotheses regarding how the cognitively active process
of deliberation can result in complete behavioral inactivity; and
(iii) suggest recommendations and interventions for combatting
inertia
Fake News as a Critical Incident in Journalism
Tandoc (2018)
This study examines how American newspapers made
sense of the issue of fake news. By analysing newspaper
editorials and considering the problem of fake news as a
critical incident confronting journalism, this study found
that news organizations in the US recognize fake news as
a social problem while acknowledging the challenge in
defining it. They generally considered fake news as a
social media phenomenon thriving on political
polarization driven by mostly ideological, but sometimes
also financial, motivations. Therefore, they assigned
blame for the rise of fake news to the current political
environment, to technological platforms Google and
Facebook, and to audiences.
Canadian hospital nurses' roles in
communication and decision-making about
goals of care: An interpretive description of
critical
Strachan (2018)

Abstract

Background

Nurses in acute medical units are uniquely positioned to

support goals of care communication. Further
understanding of nurse and physician perceptions about
hospital nurses' actual and possible roles was required to
improve goals of care communication.
The critical incident technique reappraised:
Using critical incidents to illuminate
organizational practices and build theory
Gregory Bott, Dennis Tourish (2016)

Qualitative Research in Organizations and Management:

An International Journal, 2016

Purpose

The purpose of this paper is to offer a reconceptualization

of the critical incident technique (CIT) and affirm its
utility in management and organization studies.

Design/methodology/approach

Utilizing a case study from a leadership context, the

paper applies the CIT to explore various leadership
behaviours in the context of nonprofit boards in Canada.
Semi-structured critical incident interviews were used to
collect behavioural data from 53 participants – board
chairs, board directors, and executive directors – from 18
diverse nonprofit organizations in Alberta, Canada.

Findings

While exploiting the benefits of a typicality of events, in

some instances the authors were able to validate aspects
of transformational leadership theory, in other instances
the authors found that theory falls short in explaining the
relationships between organizational actors. The authors
argue that the CIT potentially offers the kind of “thick
description” that is particularly useful in theory building in
the field.
Crisis management and incident management
in the digital era
(Thurai 2021)

An "incident" is defined as unplanned downtime, or

interruption, that either partially or fully disrupts a
service by offering a lesser quality of service to the users.
If the Incident is major, then it is a "crisis."

When it starts to affect the quality of service delivered to

the customers, it becomes an issue, as most service
provides have service level agreements with the
consumers that often have penalties built in.

As I continue my research in these areas, and after

talking to multiple clients, I have come to the realization
that most enterprises are not set up to handle IT-related
incidents or crises in real time. The classic legacy
enterprises are set up to deal with crises in old-fashioned
ways, without considering the Cloud or the SaaS model,
and social media venting brings another quirk. Newer
digital native companies do not put much emphasis on
crisis management, from what I have seen.

Especially with the need and demand for "always-on,"

incidents do not wait for a convenient time. Problems
can, and often do, happen on weekends, holidays, or
weeknights when no one is paying attention. When an
incident happens, a properly prepared enterprise must be
in a situation to identify, assess, manage, solve, and
effectively communicate it to the customers.

Another key issue to note here is the difference between

security and service incidents. A security incident is when
either data leakage or data breach happens. The
mitigation and crisis management there involves a
different set of procedures, from disabling the accounts
to notifying stakeholders and account owners and
escalating the issue to security and identity teams. A
service incident is when a service disruption happens,
either partially or fully. It needs to be escalated to
DevOps, developers and Ops teams. Since they are
similar, some of the crisis management procedures might
overlap. But if your support teams are not aware of the
right escalation process, then they might be sending
critical alerts up the wrong channel when minutes matter
in a critical situation. For the sake of this article, I am
going to be discussing only service interruptions, though
a lot of parallels can be drawn to a security incident as
well.
Using the Critical Incident Technique (CIT)
to Explore How Students Develop Their
Understanding of
Social Work Values and Ethics in the
Workplace During
Their Final Placement

Papouli (2016)

Abstract

This paper presents and discusses the findings of a

study that explored how social work students develop

their understanding of social work values and ethics

in the workplace during their final placement by

utilizing critical incident technique (CIT). The CIT

was found to be an effective qualitative research

method to explore aspects of the process of the

students’ ethics learning and development in the

course of their field placement and as such, it can

be used to identify whether the philosophy of the

practice environment is congruent with the mission,

values and ethics of the social work profession

The critical incident technique reappraised: Using
critical incidents to illuminate organizational
practices and build theory

Gregory Bott, Dennis Tourish (2016)

Qualitative Research in Organizations and Management:

An International Journal, 2016

Purpose

The purpose of this paper is to offer a reconceptualization

of the critical incident technique (CIT) and affirm its
utility in management and organization studies.

Design/methodology/approach

Utilizing a case study from a leadership context, the

paper applies the CIT to explore various leadership
behaviours in the context of nonprofit boards in Canada.
Semi-structured critical incident interviews were used to
collect behavioural data from 53 participants – board
chairs, board directors, and executive directors – from 18
diverse nonprofit organizations in Alberta, Canada.

Findings

While exploiting the benefits of a typicality of events, in

some instances the authors were able to validate aspects
of transformational leadership theory, in other instances
the authors found that theory falls short in explaining the
relationships between organizational actors. The authors
argue that the CIT potentially offers the kind of “thick
description” that is particularly useful in theory building in
the field.
The critical incident technique

Olivier Serrat(2017)

Knowledge solutions, 1077-1083, 2017

Organizations are often challenged to identify and resolve

workplace problems. The Critical Incident technique gives
them a starting point and a process for advancing
organizational development through learning
experiences. It helps them study “what people do” in
various situations.
Fake News as a Critical Incident in Journalism

Tandoc (2018)
ABSTRACT

This study examines how American newspapers made

sense of the issue of fake news. By analysing newspaper
editorials and considering the problem of fake news as a
critical incident confronting journalism, this study found
that news organizations in the US recognize fake news as
a social problem while acknowledging the challenge in
defining it. They generally considered fake news as a
social media phenomenon thriving on political
polarization driven by mostly ideological, but sometimes
also financial, motivations. Therefore, they assigned
blame for the rise of fake news to the current political
environment, to technological platforms Google and
Facebook, and to audiences.
The critical incident technique: method or
methodology?
Viergever (2019)

Qualitative health research 29 (7), 1065-1079, 2019

The critical incident technique (CIT) is a qualitative

research tool that is frequently used in health services
research to explore what helps or hinders in providing
good quality care or achieving satisfaction with care
provision. However, confusion currently exists on the
nature of the CIT: Is it a method for data collection and
analysis or a methodology? In this article, I explain why
this distinction is important and I argue that the CIT is a
methodology (and not a method) for the following
reasons: Key methodological dimensions are described
for the CIT; it has a clear focus; studies that apply this
technique make use of various methods for data
collection and analysis; it describes, explains, evaluates,
and justifies the use of a specific format for those
methods; it implies philosophical and practical
assumptions; and studies that use the CIT cannot easily
make use of additional methodologies simultaneously.
Critical Incidents from Students-Teachers’
Action Research Teaching Journals in Pre-
Service Teacher Education Program

Permatasari (2018)

Abstract

This paper presents a study about critical incidents in

Action Research Teaching Journal (ARTJS) in
Microteaching which comprised in five sections: topic,
planning, action, observation and reflection. ARTJS was
made before and after doing each mini teaching. Twelve
ARTJSs were collected from four student-teachers who
had taken Microteaching course. A descriptive data
analysis was used to identify types of critical incidents
found in ARTJSs by using NVIVO software tool. A critical
incident has been defined as, “unanticipated events that
occur during a lesson and trigger insights about some
aspect of teaching and learning” (Farrel, 2005, pp.114-
115), that lead them to be reflective teachers in ELT. The
analysis began with coding the sections of the teaching
journals which reflected types of critical incidents, then
classified similar types of critical incidents into categories.
The last step in the analysis was to interpret the
categorized data. The analysis of the data shows that
there were seven prominent themes that emerged from
this study: course delivery problems, students’
participation, time management, technical problems,
language proficiency problems and course preparation.
The paper ends with some recommendation for
improvement of Microteaching course.
Covid-19: Many hospitals “are not declaring
critical incidents” despite severe pressures
Torjesen (2022)

Abstract:The number of official critical incidents declared

by NHS hospital trusts is likely to massively
underestimate the real severity of the situation in NHS
acute care, a senior leader has told The BMJ.

Last week at least 24 of England’s 137 NHS trusts

officially declared critical incidents, many of which were
driven by staff absences because of covid-19. But while
declaring a critical incident is the formal mechanism for
signalling that priority services at the organisation may
be under threat,1 other trusts have opted not to declare
one despite struggling with similar levels of patient
demand and staff absences.

For example, hospitals in Greater Manchester suspended

some non-urgent appointments and surgery because of
workload pressures but did not declare a critical incident.

Nick Scriven, past president of the Society of Acute

Medicine and a consultant in acute medicine at
Calderdale and Huddersfield NHS Foundation Trust, told
The BMJ that the actual number of hospitals facing critical
pressures could be three times the official number. He
said that there was no incentive for hospitals to declare a
critical incident because it brought no additional support
or practical help but at the same time increased the
scrutiny and attention on them.

Scriven said, “I’ve heard it said on multiple occasions:

‘We could declare a critical incident, but it doesn’t get us
anything, we’d get no practical help—it just brings us
reams of paperwork and inspections.’”

Critical Incidents for Teachers’ Professional

Development
Joshi (2018)

Abstract:

Analysis of critical incidents is one of the approaches of

teacher professional

development. A critical incident is any unplanned event

which takes place during

the class. It is something we interpret as a problem or

challenge in a particular

context, rather than a routine occurrence. The incident is

said to be critical

because it is valuable and has some meaning. In other

words, incidents happen

but critical incidents are created because of their

importance. Teachers can

critically analyze any of their lessons and can make a

particular event critical

by reflecting on it. The teachers ask not only what

happened but also why it

happened. They then use the incidents for future

reference. This article deals

with the benefits of critical incidents and the ways to

analyze them, which lead to
successful teacher professional development

Using the Critical Incident Technique (CIT)

to Explore How Students Develop Their
Understanding of
Social Work Values and Ethics in the
Workplace During
Their Final Placement

Papouli (2016)

Abstract

This paper presents and discusses the findings of a

study that explored how social work students develop

their understanding of social work values and ethics

in the workplace during their final placement by

utilizing critical incident technique (CIT). The CIT

was found to be an effective qualitative research

method to explore aspects of the process of the

students’ ethics learning and development in the

course of their field placement and as such, it can

be used to identify whether the philosophy of the

practice environment is congruent with the mission,

values and ethics of the social work profession.

Keywords: critical incident technique (CIT); social

work values and ethics; social work students; field

placement; Greece

Coordination in Crises: Implementation of the

National Incident Management System by
Surface Transportation Agencies
Hambridge (2017)

Abstract

For more than a decade, the National Incident

Management System (NIMS) has served in the United
States as the mandated framework for coordinated
organization, operational command, and implementation
of response to emergencies nationwide. This article
examines whether surface transportation agencies are
developing the capabilities necessary to fit effectively into
NIMS. It reviews the literature on NIMS, focusing on its
implementation in “second and third circle responder”
professions, including transportation, rather than in
traditional first responder fields such as police, fire, EMS,
and emergency management. The article also reports on
exploratory interviews with city, metro, state, and federal
transportation officials about the extent of NIMS
implementation and the factors that facilitate or impede
its use. Finally, we present a consolidated conceptual
model of factors influencing NIMS implementation and
make recommendations about how to enhance NIMS use
in the transportation sector.

Critical Incident Stress Debriefing From a

Traumatic Event
Davis(2013)

Abstract:

Using Critical Incident Stress Debriefing (CISD) in the

Post-ventive Aftermath

Caught off guard and "numb" from the impact of a critical

incident, employers and employees are often ill-equipped
to handle the chaos of such a catastrophic event like
workplace violence. Consequently, survivors of such an
event often struggle to regain control of their lives to
recover a sense of normalcy. Additionally, many who
have been traumatized by a critical life-changing event
may eventually need professional attention and care for
weeks, months, and possibly years to come.

The final extent of any traumatic event may never be

known or realistically estimated in terms of loss,
bereavement, mourning, and grief. In the aftermath of
any critical incident, psychological reactions are quite
common and are quite predictable. Critical Incident
Stress Debriefing or CISD and the management of
traumatic reactions by survivors can be a valuable tool
following a life-threatening event.
Since the mid-1980s, following many high profile events
tied to the United States Postal Service, the need to
provide victim assistance to employees in the workplace
setting has received more positive attention than ever
before. This prevention and intervention movement has
gained a lot of momentum with the passage of state and
federal legislation designed to protect, provide resources
and services to those who are physically or emotionally
traumatized in the workplace.

As part of a corporate Human Resources Division

strategy, an HR administrator can employ, train and
deploy trauma specialists to provide direct, face-to-face
contact or phone contact as part of an overall Crisis
Response Teams (CRT) program. This integrated team
acts to off-set risk, mitigate fall-out, and enhance
recovery and sustainability in the event of an acute or
short-term man-made or natural workplace stoppage.
Additionally, trauma specialists can be identified in
nearby locations, if not on-site, and respond quickly by
being placed on-call or on "stand-by" (ready alert)
regardless of the situation. This is an absolute must
legally, ethically, and morally should a catastrophic event
occur.

Analysis of Critical Incidents during

Anesthesia in a Tertiary Hospital
Zeng(2016)

Abstract:

Introduction: Critical incident monitoring is important in

quality improvement as it identifies potential risks to
patients by analyzing adverse events or near-misses.
Methods: This study analyses the reported incidents in a
tertiary hospital over a 4-year period. Results: A total of
441 incidents were reported out of 98,502 anesthetics
performed during the study period. Of these incidents, 67
resulted in no harm caused, 116 with unanticipated ICU
admissions and 20 mortalities. The odds of having a
critical incident increased with ASA status: from an odds
ratio of 2.08 (95% CI: 1.58 to 2.74) for ASA 2 patients
compared to ASA1, to OR of 13.70 (5.91 to 31.74) in
ASA 5 compared to ASA 1. Critical incidents also have
higher odds occurring out of hours (OR 1.7 (1.45 to 2.23)
compared to daytime hours (08:00-17:00). They
occurred most commonly in maintenance phase (142,
32.7%), followed by induction (120, 27.6%). The most
common types of incidents include airway and respiratory
(110, 24.9%) followed by drug related incidents (67,
15.2%). Human error was attributed as a significant
contributing factor in 276 incidents (61.5%) followed by
patient factors in 112 incidents (25.4%). Mitigating
factors such as vigilance by staff involved were significant
in 136 incidents (30.3%). Conclusion: Higher ASA status
appears to be the most important factor associated with
actual or potential patient harm in our study. Also
significant, was time of incident, with incidents more
likely out of hours. Critical incident reporting is a valuable
part of quality assurance. We should continue to invest in
incident reporting, incident analysis and improvement
plans.

Leadership in a crisis: Responding to the

coronavirus outbreak and future challenges
Smet(2020)

Article:

The coronavirus pandemic has placed extraordinary

demands on leaders in business and beyond. The
humanitarian toll taken by COVID-19 creates fear among
employees and other stakeholders. The massive scale of
the outbreak and its sheer unpredictability make it
challenging for executives to respond. Indeed, the
outbreak has the hallmarks of a “landscape scale” crisis:
an unexpected event or sequence of events of enormous
scale and overwhelming speed, resulting in a high degree
of uncertainty that gives rise to disorientation, a feeling
of lost control, and strong emotional disturbance

Recognizing that a company faces a crisis is the first

thing leaders must do. It is a difficult step, especially
during the onset of crises that do not arrive suddenly but
grow out of familiar circumstances that mask their
nature.2 Examples of such crises include the SARS
outbreak of 2002–03 and now the coronavirus pandemic.
Seeing a slow-developing crisis for what it might become
requires leaders to overcome the normalcy bias, which
can cause them to underestimate both the possibility of a
crisis and the impact that it could have.3

Once leaders recognize a crisis as such, they can begin to

mount a response. But they cannot respond as they
would in a routine emergency, by following plans that
had been drawn up in advance. During a crisis, which is
ruled by unfamiliarity and uncertainty, effective
responses are largely improvised.4 They might span a
wide range of actions: not just temporary moves (for
example, instituting work-from-home policies) but also
adjustments to ongoing business practices (such as the
adoption of new tools to aid collaboration), which can be
beneficial to maintain even after the crisis has passed.

What leaders need during a crisis is not a predefined

response plan but behaviors and mindsets that will
prevent them from overreacting to yesterday’s
developments and help them look ahead. In this article,
we explore five such behaviors and accompanying
mindsets that can help leaders navigate the coronavirus
pandemic and future crises