Report of Task Force into Critical Incidents within the Iowa Prison System, 2004

Report #02-04 Concerns about the death of two Iowa inmates at the Anamosa State Penitentiary, asked the Ombudsman Office to review the incidents and provide an assessment of each incident. The Governor also asked the Ombudsman Office to propose a set of recommendations for improving inmate and staff safety within Anamosa State Penitentiary.

Documents as 'critical incidents' in organisation to consumer communication

A diary study tracked the paper documents received by nine UK informants over one month. Informants gave simple ratings of individual documents’ attractiveness and the ease of understanding them; more detailed reactions to the documents were gathered through informant diaries and follow-up interviews. The detailed reactions extended beyond the feedback gathered through the rating task. Informants showed sensitivity to the content, language, design and circumstances of receipt of documents, with indications that they developed opinions of originating organizations based on their experience of using their documents. Documents that failed to provide all the information needed, that failed to make their intentions clear (or obscured their intentions) or that were perceived as miss-targeted received negative comment. Repeat experiences of receiving either well- or poorly-conceived documents strengthened informant reactions to individual originating organizations. The paper concludes with recommendations for steps document originators, writers and designers need to take to prepare documents that enhance organization to consumer communication. We recommend that organizations evaluate and act on consumers’ reactions to their documents, beyond user testing in document development or scorecard ratings in use.

Dynamics of critical incidents with potentially violent outcomes involving ultra fans: an explorative study

This study examines incidents involving a tense atmosphere combined with higher risk of football fan violence. A systematic description of such critical incidents (CIs) identifying their risk factors and warning signs is yet lacking. This study looks beyond fans’ violent acts per se and focuses on CIs involving ultra fans with a potentially – but not necessarily – violent outcome. A preliminary study involving a focus group was conducted followed by a main study including eight case studies. The focus group comprised five professionals working with football fans who discussed CIs’ observable characteristics. Risk factors and warning signs were coded using content analysis, such as, ‘arrest of a fan’. In the main study, people involved in actual CIs were interviewed to explore these phenomena in more depth. An integrated model of CIs’ dynamics, risk factors and warning signs was compiled using data gathered in both studies.

Evaluation of an inventory for the assessment of critical incidents involving football fans

Introduction: Fan violence is a frequent occurrence in Swiss football (Bundesamt für Polizei, 2015) leading to high costs for prevention and control (Mensch & Maurer, 2014). Various theories put forward an explanation of fan violence, such as the Elaborated Social Identity Model (Drury & Reicher, 2000)and the Aggravation Mitigation Model (Hylander & Guvå, 2010). Important observations from these theories are the multi-dimensional understanding of fan violence and the Dynamics occurring in the fan group. Nevertheless, none of them deal with critical incidents (CIs) which involve a tense atmosphere combined with a higher risk of fan violence. Schumacher Dimech, Brechbühl and Seiler (2015) tackled this gap in research and explored CIs where 43 defining criteria were identified and compiled in an integrated model of CIs. The defining criteria were categorised in four higher-order themes “antecedents” (e.g. a documented history of fan rivalry), “triggers” (e.g. the arrest of a fan), “reactions” (e.g. fans masking themselves) and “consequences” (e.g. fans avoiding communication with fan social workers). Methods: An inventory based on this model is being developed including these 43 criteria. In an exploratory phase, this inventory was presented as an online questionnaire and was completed by 143 individuals. Three main questions are examined: Firstly, the individual items are tested using descriptive analyses. An item analysis is conducted to test reliability, item difficulty and discriminatory power. Secondly, the model’s four higher-order themes are tested using exploratory factor analysis (EFA). Thirdly, differences between sub -groups are explored, such as gender and age-related differences. Results: Respondents rated the items’ importance as high and the quota of incomplete responses was not systematic. Two items were removed from the inventory because of low mean or a high rate of “don’t know”-responses. EFA produced a six-factor solution grouping items into match-related factors, repressive measures, fans’ delinquent behaviour, intra-group behaviour, communication and control and inter-group factors. The item “fans consume alcohol” could not be ordered into any category but was retained since literature accentuates this factor’s influence on fan violence. Analyses examining possible differences between groups are underway. Discussion: Results exploring the adequacy of this inventory assessing defining criteria of CIs in football are promising and thus further evaluative investigation is recommended. This inventory can be used in two ways: as a standardised instrument of assessment for experts evaluating specific CIs and as an instrument for exploring differences in perception and assessment of a CI e.g. gender and age differences, differences between interest groups and stakeholders.

Evaluation of an inventory for the assessment of critical incidents involving football fans

Introduction: Fan violence is a frequent occurrence in Swiss football (Bundesamt für Polizei, 2015) leading to high costs for prevention and control (Mensch & Maurer, 2014). Various theories put forward an explanation of fan violence, such as the Elaborated Social Identity Model (Drury & Reicher, 2000) and the Aggravation Mitigation Model (Hylander & Guvå, 2010). Important observations from these theories are the multi-dimensional understanding of fan violence and the dynamics occurring in the fan group. Nevertheless, none of them deal with critical incidents (CIs) which involve a tense atmosphere combined with a higher risk of fan violence. Schumacher Dimech, Brechbühl and Seiler (2015) tackled this gap in research and explored CIs where 43 defining criteria were identified and compiled in an integrated model of CIs. The defining criteria were categorised in four higher-order themes “antecedents” (e.g. a documented history of fan rivalry), “triggers” (e.g. the arrest of a fan), “reactions” (e.g. fans masking themselves) and “consequences” (e.g. fans avoiding communication with fan social workers). Methods: An inventory based on this model is being developed including these 43 criteria. In an exploratory phase, this inventory was presented as an online questionnaire and was completed by 143 individuals. Three main questions are examined: Firstly, the individual items are tested using descriptive analyses. An item analysis is conducted to test reliability, item difficulty and discriminatory power. Secondly, the model’s four higher-order themes are tested using exploratory factor analysis (EFA). Thirdly, differences between sub-groups are explored, such as gender and agerelated differences. Results: Respondents rated the items’ importance as high and the quota of incomplete responses was not systematic. Two items were removed from the inventory because of low mean or a high rate of “don’t know”-responses. EFA produced a six-factor solution grouping items into match-related factors, repressive measures, fans’ delinquent behaviour, intra-group behaviour, communication and control and inter-group factors. The item “fans consume alcohol” could not be ordered into any category but was retained since literature accentuates this factor’s influence on fan violence. Analyses examining possible differences between groups are underway. Discussion: Results exploring the adequacy of this inventory assessing defining criteria of CIs in football are promising and thus further evaluative investigation is recommended. This inventory can be used in two ways: as a standardised instrument of assessment for experts evaluating specific CIs and as an instrument for exploring differences in perception and assessment of a CI e.g. gender and age differences, differences between interest groups and stakeholders. References: Bundesamt für Polizei. (2015). Jahresbericht 2014. Kriminalitätsbekämpfung Bund. Lage, Massnahmen und Mittel [Electronic Version]. Drury, J., & Reicher, S. (2000). Collective action and psychological change. The emergence of new social identities. British Journal of Social Psychology, 39, 579-604. Hylander, I., & Guvå, G. (2010). Misunderstanding of out-group behaviour: Different interpretations of the same crowd events among police officers and demonstrators. Nordic Psychology, 62, 25-47. Schumacher-Dimech, A., Brechbühl, A. &, Seiler, R. (2016). Dynamics of critical incidents with potentially violent outcomes involving ultra fans: an explorative study. Sport in Society. Advance online publication. doi: 10.1080/17430437.2015.1133597

Travel behaviour change in old age : the role of critical incidents in public transport

Older people’s travel behaviour is affected by negative or positive critical incidents in the public transport environment. With the objective of identifying such inci- dents during whole trips and examining how travel beha- viour had changed, we have conducted in-depth interviews with 30 participants aged 65–91 years in the County of Stockholm, Sweden. Out of 469 incidents identified, 77 were reported to have resulted in travel behaviour change, 67 of them in a negative way. Most critical incidents were encountered in the physical environment on-board vehicles and at stations/stops as well as in pricing/ticketing. The findings show that more personal assistance, better driving behaviour, and swift maintenance of elevators and escala- tors are key facilitators that would improve predictability in travelling and enhance vulnerable older travellers’ feeling of security. The results demonstrate the benefit of involving different groups of end users in future planning and design, such that transport systems would meet the various needs of its end users.

An analysis of beginning mentors’ critical incidents in English post-compulsory education: navigating stormy waters

This qualitative study explores the barriers and dilemmas faced by beginning and novice mentors in post-compulsory education in the southeast of England. It analyses critical incidents (Tripp, 2012) taken from the everyday practice of mentors who were supporting new teachers and lecturers in the southeast of England. It categorises different types of critical incidents that mentors encountered and describes the strategies and rationales mentors used to support mentees and (indirectly) their learners and colleagues. The study explores ways in which mentors' own values, beliefs and life experiences affected their mentoring practice.  Methodology As part of a specialist master’s-level professional development module, 21 mentors wrote about two critical incidents (Tripp, 2012) taken from their own professional experiences, which aimed to demonstrate their support for their mentee’s range of complex needs. These critical incidents were written up as short case studies, which justified the rationale for their interventions and demonstrated the mentors' own professional development in mentoring. Critical incidents were used as units of analysis and categorised thematically by topic, sector and mentoring strategies used. Findings The research demonstrated the complex nature of decision-making and the potential for professional learning within a mentoring dyad. The study of these critical incidents found that mentors most frequently cited the controversial nature of teaching observations, the mentor’s role in mediating professional relationships, the importance of inculcating professional dispositions in education, and the need to support new teachers so that they can use effective behaviour management strategies. This study contributes to our understanding of the central importance of mentoring for professional growth within teacher education. It identifies common dilemmas that novice mentors face in post-compulsory education, justifies the rationale for their interventions and mentoring strategies, and helps to identify ways in which mentors' professional development needs can be met. It demonstrates that mentoring is complex, non-linear and mediated by mentors’ motivation and values.

Critical incident analysis through narrative reflective practice: A case study

Teachers can reflect on their practices by articulating and exploring incidents they consider critical to themselves or others. By talking about these critical incidents, teachers can make better sense of seemingly random experiences that occur in their teaching because they hold the real inside knowledge, especially personal intuitive knowledge, expertise and experience that is based on their accumulated years as language educators teaching in schools and classrooms. This paper is about one such critical incident analysis that an ESL teacher in Canada revealed to her critical friend and how both used McCabe’s (2002) narrative framework for analyzing an important critical incident that occurred in the teacher’s class.

Some theoretical and methodological considerations for the development of a critical competences model (CCM): an operant approach

This paper develops some theoretical and methodological considerations for the development of a critical competence model (CCM). The model is defined as a set of skills and knowledge functionally organized allowing measurable results with positive consequences for the strategic business objectives. The theoretical approaches of classical model of competences, the contemporary model of competencies and human competencies model were revised for the proposal development. implementation of the model includes 5 steps: 1) conducting a job analysis considering which dimensions or facets are subject to revision, 2) identify people with the opposite performance (the higher performance and lower performance); 3) identify critical incidents most relevant to the job position, 4) develop behavioral expectation scales (bes) and 5) validate BES obtained for experts in the field. As a final consideration, is determined that the competence models require accurate measurement. Approaches considering excessive theoreticism may cause the issue of competence become a fashion business with low or minimal impact, affecting its validity, reliability and deployment in organizations.

Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes?

PURPOSE OF REVIEW: Critical incident reporting alone does not necessarily improve patient safety or even patient outcomes. Substantial improvement has been made by focusing on the further two steps of critical incident monitoring, that is, the analysis of critical incidents and implementation of system changes. The system approach to patient safety had an impact on the view about the patient's role in safety. This review aims to analyse recent advances in the technique of reporting, the analysis of reported incidents, and the implementation of actual system improvements. It also explores how families should be approached about safety issues. RECENT FINDINGS: It is essential to make as many critical incidents as possible known to the intensive care team. Several factors have been shown to increase the reporting rate: anonymity, regular feedback about the errors reported, and the existence of a safety climate. Risk scoring of critical incident reports and root cause analysis may help in the analysis of incidents. Research suggests that patients can be successfully involved in safety. SUMMARY: A persisting high number of reported incidents is anticipated and regarded as continuing good safety culture. However, only the implementation of system changes, based on incident reports, and also involving the expertise of patients and their families, has the potential to improve patient outcome. Hard outcome criteria, such as standardized mortality ratio, have not yet been shown to improve as a result of critical incident monitoring.

[Second victim : Critical incident stress management in clinical medicine]

BACKGROUND Critical incidents in clinical medicine can have far-reaching consequences on patient health. In cases of severe medical errors they can seriously harm the patient or even lead to death. The involvement in such an event can result in a stress reaction, a so-called acute posttraumatic stress disorder in the healthcare provider, the so-called second victim of an adverse event. Psychological distress may not only have a long lasting impact on quality of life of the physician or caregiver involved but it may also affect the ability to provide safe patient care in the aftermath of adverse events. METHODS A literature review was performed to obtain information on care giver responses to medical errors and to determine possible supportive strategies to mitigate negative consequences of an adverse event on the second victim. An internet search and a search in Medline/Pubmed for scientific studies were conducted using the key words "second victim, "medical error", "critical incident stress management" (CISM) and "critical incident stress reporting system" (CIRS). Sources from academic medical societies and public institutions which offer crisis management programs where analyzed. The data were sorted by main categories and relevance for hospitals. Analysis was carried out using descriptive measures. RESULTS In disaster medicine and aviation navigation services the implementation of a CISM program is an efficient intervention to help staff to recover after a traumatic event and to return to normal functioning and behavior. Several other concepts for a clinical crisis management plan were identified. CONCLUSIONS The integration of CISM and CISM-related programs in a clinical setting may provide efficient support in an acute crisis and may help the caregiver to deal effectively with future error events and employee safety.

Critical incidence reporting systems - an option in equine anaesthesia? Results from a panel meeting.

OBJECTIVE To provide a brief introduction into Critical Incident Reporting Systems (CIRS) as used in human medicine, and to report the discussion from a recent panel meeting discussion with 23 equine anaesthetists in preparation for a new CEPEF-4 (Confidential Enquiry into Perioperative Equine Fatalities) study. STUDY DESIGN Moderated group discussions, and review of literature. METHODS The first group discussion focused on the definition of 'preventable critical incidents' and/or 'near misses' in the context of equine anaesthesia. The second group discussion focused on categorizing critical incidents according to an established framework for analysing risk and safety in clinical medicine. RESULTS While critical incidents do occur in equine anaesthesia, no critical incident reporting system including systematic collection and analysis of critical incidents is in place. CONCLUSIONS AND CLINICAL RELEVANCE Critical incident reporting systems could be used to improve safety in equine anaesthesia - in addition to other study types such as mortality studies.