Naturalistic decision making in after‐action review meetings: The implementation of and learning from post‐fall huddles

Abstract

The purpose of this study was to add to our understanding of Naturalistic Decision Making (NDM) in healthcare, and how After Action Reviews (AARs) can be utilized as a learning tool to reduce errors. The study focused on the implementation of a specific form of AAR, a post-fall huddle, to learn from errors and reduce patient falls. Utilizing 17 hospitals that participated in this effort, information was collected on 226 falls over a period of 16 months. The findings suggested that the use of self-guided post-fall huddles increased over the time of the project, indicating adoption of the process. Additionally, the results indicate that the types of errors identified as contributing to the patient fall changed, with a reduction in task and coordination errors over time. Finally, the proportion of falls with less adverse effects (such as non-injurious falls) increased during the project time period. The results of this study fill a void in the NDM and AAR literature, evaluating the role of NDM in healthcare specifically related to learning from errors. Over time, self-guided AARs can be useful for some aspects of learning from errors.

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

“…Debriefing, including after event huddles, assume varying structures but share the core characteristic of process-oriented, ‘rigorous reflection’ to find actionable solutions 73. The literature uses the terms huddle and debriefing interchangeably 74 75. They frequently occur as part of a clinical workflow.…”

“…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…”

“…Literature suggests numerous benefits for debriefing in healthcare. They have been linked to improved safety, team culture and clinical performance 74 75 77 85 94–96. Team members report feeling supported by colleagues after an adverse event debriefing 74 97.…”

Do safety briefings improve patient safety in the acute hospital setting? A systematic review

“…Three studies were qualitative (Goldenhar, Brady, Sutcliffe, & Muething, ; Pannick, Archer, et al., ; Provost, Lanham, Leykum, McDaniel, & Pugh, ) and nine were quantitative (Brady et al., ; Menon et al., ; Mullan, Macias, Hsu, Alam, & Patel, ; Newman, Bingler, Bauer, Lee, & Mann, ; Pannick, Athanasiou, Long, Beveridge, & Sevdalis, ; Reiter‐Palmon et al. ; Ruggiero, Smith, Copeland, & Boxer, ; Saysana, McCaskey, Thompson, Tuttle, & Haut, ; Warsame et al., ). All nine of the quantitative studies used quality improvement methodologies.…”

“…All were based in acute hospitals, four of which were paediatric settings (Brady et al., ; Goldenhar et al., ; Mullan et al., ; Saysana et al., ). Four studies incorporated general medical and surgical units in multiple hospitals (Pannick, Archer, et al., ; Pannick, Athanasiou, et al., ; Provost et al., ; Reiter‐Palmon, Kennel, Allen, Jones, & Skinner, ). The remaining eight were single site studies and included the settings of emergency care (Mullan et al., ), haematology (Warsame et al.…”