After-action reviews: The good behavior, the bad behavior, and why we should care

Crowe, John; Allen, Joseph A.; Scott, Cliff; Harms, Mackenzie; Yoerger, Michael

doi:10.1016/j.ssci.2017.03.006

Cited by 21 publications

(21 citation statements)

References 49 publications

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“…These results are consistent with studies that have reported improved perceptions of safety culture in association with the adoption of structured team strategies and tools [33, 35, 36]. Finally, our results are consistent with previous research describing the positive impact of AARs on outcomes in healthcare [22, 23] and other contexts [19].…”

Section: Discussionsupporting

confidence: 93%

“…A meta-analysis revealed that effective AARs may improve team performance by 25% through retrospective learning as team members make sense of an event to improve future performance [18]. This sensemaking requires a psychologically safe environment, which is most likely to occur when a facilitator guides the team to discuss what went well, what went poorly, what almost went poorly, and what will be done differently moving forward [19].…”

Section: Introductionmentioning

confidence: 99%

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The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

Jones

Crowe

Allen

et al. 2019

BMC Health Serv Res

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Background Conducting post-fall huddles is considered an integral component of a fall-risk-reduction program. However, there is no evidence linking post-fall huddles to patient outcomes or perceptions of teamwork and safety culture. The purpose of this study is to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture. Methods During a two-year demonstration project, we developed a system for 16 small rural hospitals to report, benchmark, and learn from fall events, and we trained them to conduct post-fall huddles. To calculate a hospital’s repeat fall rate, we divided the total number of falls reported by the hospital by the number of unique medical record numbers associated with each fall. We used Spearman correlations with exact P values to determine the association between the proportion of falls followed by a huddle and the repeat fall rate. At study end, we used the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) to assess perceptions of teamwork support for fall-risk reduction and the Hospital Survey on Patient Safety Culture (HSOPS) to assess perceptions of safety culture. We added an item to the T-TPQ for respondents to indicate the number of post-fall huddles in which they had participated. We used a binary logistic regression with a logit link to examine the effect of participation in post-fall huddles on respondent-level percent positive T-TPQ and HSOPS scores. We accounted for clustering of respondents within hospitals with random effects using the GLIMMIX procedure in SAS/STAT. Result Repeat fall rates were negatively associated with the proportion of falls followed by a huddle. As compared to hospital staff who did not participate in huddles, those who participated in huddles had more positive perceptions of four domains of safety culture and how team structure, team leadership, and situation monitoring supported fall-risk reduction. Conclusions Post-fall huddles may reduce the risk of repeat falls. Staff who participate in post-fall huddles are likely to have positive perceptions of teamwork support for fall-risk reduction and safety culture because huddles are a team-based approach to reporting, adapting, and learning.

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Section: Discussionsupporting

confidence: 93%

Section: Introductionmentioning

confidence: 99%

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

Jones

Crowe

Allen

et al. 2019

BMC Health Serv Res

Self Cite

View full text Add to dashboard Cite

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“…Experiences with both anticipated and unanticipated adverse events represent opportunities for learning and the development of positive adaptations for individuals and their contributions to the team. As such, systematic reflection plays an important role for the enhancement and refinement of team resilience (also referred to as after‐event or after‐action reviews; Crowe, Allen, Scott, Harms, & Yoerger, ; Ellis & Davidi, ). Systematic reflection involves (1) learning from failures and successes in performance by analysing one's behaviour and generating the most plausible explanations of behavioural processes and their links to performance outcomes; (2) exploring alternative perspectives on how things might have occurred (i.e., counterfactual thinking); and (3) evaluating performance in terms of success or failure and the underlying causal processes associated with these outcomes (Ellis, Carette, Anseel, & Lievens, ).…”

Section: Model Overview and Key Propositionsmentioning

confidence: 99%

The emergence of team resilience: A multilevel conceptual model of facilitating factors

Gucciardi

Crane

Ntoumanis

et al. 2018

J Occupat & Organ Psyc

102

160

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With empirical research on team resilience on the rise, there is a need for an integrative conceptual model that delineates the essential elements of this concept and offers a heuristic for the integration of findings across studies. To address this need, we propose a multilevel model of team resilience that originates in the resources of individual team members and emerges as a team-level construct through dynamic person-situation interactions that are triggered by adverse events. In so doing, we define team resilience as an emergent outcome characterized by the trajectory of a team's functioning, following adversity exposure, as one that is largely unaffected or returns to normal levels after some degree of deterioration in functioning. This conceptual model offers a departure point for future work on team resilience and reinforces the need to incorporate inputs and process mechanisms inherent within dynamic interactions among individual members of a team. Of particular, importance is the examination of these inputs, process mechanisms and emergent states, and outcomes over time, and in the context of task demands, objectives, and adverse events. Practitioner pointsTeam resilience as a dynamic, multilevel phenomenon requires clarity on the individual-and team-level factors that foster its emergence within occupational and organizational settings. An understanding of the nature (e.g., timing, chronicity) of adverse events is key to studying and intervening to foster team resilience within occupational and organizational settings.

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“…Organizational practices are made that promote a higher attention to detail due to a focus on potential failure (Weick and Sutcliffe, 2001). Such a mindset allows individuals to collectively recognize and respond to error signals in their environments during the earliest stages of crisis development (Crowe et al, 2017). Previous research has explored different types of organizational practices promoting increased levels of safety performance (e.g.…”

Section: Complementary Explanation Of Unsafe Behaviormentioning

confidence: 99%

Social influence and safe behavior in manufacturing

Hald

2018

Safety Science

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After-action reviews: The good behavior, the bad behavior, and why we should care

Cited by 21 publications

References 49 publications

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

The emergence of team resilience: A multilevel conceptual model of facilitating factors

Social influence and safe behavior in manufacturing

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