RT Journal Article SR Electronic T1 Local emergency medical response after a terrorist attack in Norway: a qualitative study JF BMJ Quality & Safety JO BMJ Qual Saf FD BMJ Publishing Group Ltd SP 806 OP 816 DO 10.1136/bmjqs-2017-006517 VO 26 IS 10 A1 Aleidis S Brandrud A1 Michael Bretthauer A1 Guttorm Brattebø A1 May JB Pedersen A1 Kent Håpnes A1 Karin Møller A1 Trond Bjorge A1 Bjørnar Nyen A1 Lars Strauman A1 Ada Schreiner A1 Gro S Haldorsen A1 Maria Bergli A1 Eugene Nelson A1 Tamara S Morgan A1 Per Hjortdahl YR 2017 UL http://qualitysafety.bmj.com/content/26/10/806.abstract AB Introduction On 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to the local Ringerike community hospital. All victims survived. The local emergency medical service (EMS), despite limited resources, was evaluated by three external bodies as successful in handling this crisis. This study investigates the determinants for the success of that EMS as a model for quality improvement in healthcare.Methods We performed focus group interviews using the critical incident technique with 30 healthcare professionals involved in the care of the attack victims to establish determinants of the EMS’ success. Two independent teams of professional experts classified and validated the identified determinants.Results Our findings suggest a combination of four elements essential for the success of the EMS: (1) major emergency preparedness and competence based on continuous planning, training and learning; (2) crisis management based on knowledge, trust and data collection; (3) empowerment through multiprofessional networks; and (4) the ability to improvise based on acquired structure and competence. The informants reported the successful response was specifically based on multiprofessional trauma education, team training, and prehospital and in-hospital networking including mental healthcare. The powerful combination of preparedness, competence and crisis management built on empowerment enabled the healthcare workers to trust themselves and each other to make professional decisions and creative improvisations in an unpredictable situation.Conclusion The determinants for success derived from this qualitative study (preparedness, management, networking, ability to improvise) may be universally applicable to understanding the conditions for resilient and safe healthcare services, and of general interest for quality improvement in healthcare.