G75 The rapid debrief: a tool that transforms learning and system change

Abstract

42%). 3 This audit aims to survey the availability of paediatric DATs and difficult airway equipment in regional paediatric emergency units. Methods A standard questionnaire for DAT and difficult airway equipment was devised according to the RCPCH guideline. 4 In February 2014, data was collected from senior nursing staff in all 34 regional paediatric EDs via telephone, email or in person. Results 30 out of 34 units were included. Only 40% had a paediatric DAT on the unit, although all units had some paediatric difficult intubation equipment. A significant number of departments did not have capnography recording (23%), cuffed endotracheal tubes of all sizes (33%), or a cricoidotomy set (33%). Variation in the choice of laryngeal blades reflected individual preferences by specialists. 90% of units kept a daily checking rota. Conclusion This survey highlights the need for improved availability of paediatric DATs and intubation equipment. Particular effort should be made to secure the more advanced equipment, and ensure the availability of a full size range for basic equipment.

Review of alternatives to root cause analysis: developing a robust system for incident report analysis

“…Checklist driven postoperative debriefings are recommended by the VHA and WHO 76–78. Debriefings and huddles may also take place after a safety event, such as a fall 74 75 79–89…”