Critical Care Transport Debrief
Please complete this debrief form after each critical care transport to support quality improvement and team learning.
Date and Time of Transport
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Team Members Involved (Full Names)
*
Patient Age Group
*
Please Select
Neonate
Pediatric
Adult
Transport Type
*
Ground Ambulance
Air Ambulance (Helicopter)
Air Ambulance (Fixed Wing)
Other
Referring Facility
*
Receiving Facility
*
Please rate the following aspects of the transport:
*
Rows
Excellent
Good
Fair
Poor
Communication between team members
1
2
3
4
Communication with sending/receiving facility
5
6
7
8
Equipment availability/function
9
10
11
12
Clinical care provided
13
14
15
16
Safety during transport
17
18
19
20
Were there any incidents or adverse events during transport?
*
No
Yes (please describe below)
If yes, please describe the incident or adverse event:
Suggestions for improvement or lessons learned
Please rate your overall satisfaction with the transport process.
*
1
2
3
4
5
Submit Debrief
Should be Empty: