The critical role of learning from investigating and debriefing adverse events

Raja, Siva; Litle, Virginia R.

doi:10.21037/jtd-2020-epts-01

Cited by 5 publications

(4 citation statements)

References 14 publications

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Section: Strategiesmentioning

confidence: 99%

“…Organizations should have a clear procedure that outlines standard debriefing steps after an event 24 . The debriefing should be framed as a “peer review” process 24 and include other staff members rather than only administrators or leaders. Peer review that includes all members of the team can help provide a supportive environment for reviewing the event and improve the safety culture of the organization 25…”

Section: Strategiesmentioning

confidence: 99%

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Creating a Just Culture in the Perioperative Setting

Hooven,

Altmiller

2024

AORN Journal

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There has been an increased perioperative focus on avoiding adverse events and providing safe patient care since To Err Is Human: Building a Safer Health System published in 2000. Adverse events continue to occur in perioperative areas and are likely underreported. The interdisciplinary nature and high cost of perioperative care may discourage personnel from speaking up for fear of retribution and punishment when reporting. Organization leaders can implement a just culture that focuses on improving patient care processes and safety rather than placing blame after an adverse event. A tenet of just culture is achieving balanced accountability between systems and individuals. Strategies for just culture implementation include leader support, policies and procedures for reporting, accessibility of reporting systems, provision of information for staff members, identification of support champions, and creation of a good catch program. Leaders also should measure and track progress associated with the just culture in their facility.

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Section: Strategiesmentioning

confidence: 99%

Section: Strategiesmentioning

confidence: 99%

Creating a Just Culture in the Perioperative Setting

Hooven,

Altmiller

2024

AORN Journal

View full text Add to dashboard Cite

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“…Historically, peer review conferences (PRC), also referred to as morbidity and mortality (M&M) conferences, have sought to improve patient care by identifying the sources of clinical error but all too frequently have taken a “shame and blame” approach[ 68 ]. PRC structure may pose additional barriers to the goal of improving patient safety based on the types of cases reviewed and the priorities of focus and skills of the facilitators.…”

Section: Introductionmentioning

confidence: 99%

Ten misconceptions regarding decision-making in critical care

Ramaswamy,

Sparling,

Chang

et al. 2024

World J Crit Care Med

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Diagnostic errors are prevalent in critical care practice and are associated with patient harm and costs for providers and the healthcare system. Patient complexity, illness severity, and the urgency in initiating proper treatment all contribute to decision-making errors. Clinician-related factors such as fatigue, cognitive overload, and inexperience further interfere with effective decision-making. Cognitive science has provided insight into the clinical decision-making process that can be used to reduce error. This evidence-based review discusses ten common misconceptions regarding critical care decision-making. By understanding how practitioners make clinical decisions and examining how errors occur, strategies may be developed and implemented to decrease errors in Decision-making and improve patient outcomes.

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“…"Errare humanum est, perseverare diabolicum ['To err is human, (but) to persist is diabolical']". Debriefings emerged from this philosophy of understanding and learning from one's mistakes (1). Developed in the military field during World War II, debriefings have been adopted by several disciplines over the decades (e.g., aviation, psychology, education, and medicine) (2).…”

Section: Introductionmentioning

confidence: 99%

A success story of clinical debriefings: lessons learned to promote impact and sustainability

Paquay

Simon²,

Ancion

et al. 2023

Front. Public Health

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The COVID-19 crisis impacted emergency departments (ED) unexpectedly and exposed teams to major issues within a constantly changing environment. We implemented post-shift clinical debriefings (CDs) from the beginning of the crisis to cope with adaptability needs. As the crisis diminished, clinicians voiced a desire to maintain the post-shift CD program, but it had to be reshaped to succeed over the long term. A strategic committee, which included physician and nurse leadership and engaged front-line staff, designed and oversaw the implementation of CD. The CD structure was brief and followed a debriefing with a good judgment format. The aim of our program was to discover and integrate an organizational learning strategy to promote patient safety, clinicians' wellbeing, and engagement with the post-shift CD as the centerpiece. In this article, we describe how post-shift CD process was performed, lessons learned from its integration into our ED strategy to ensure value and sustainability and suggestions for adapting this process at other institutions. This novel application of debriefing was well received by staff and resulted in discovering multiple areas for improvement ranging from staff interpersonal interactions and team building to hospital wider quality improvement initiatives such as patient throughput.

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The critical role of learning from investigating and debriefing adverse events

Abstract: The roots of the debriefing process for adverse events in medicine can be traced back to the anesthesia records of then medical students Harvey Cushing and Ernest Codman (1). As medical students these two future legends in and out

Cited by 5 publications

References 14 publications

Creating a Just Culture in the Perioperative Setting

Creating a Just Culture in the Perioperative Setting

Ten misconceptions regarding decision-making in critical care

A success story of clinical debriefings: lessons learned to promote impact and sustainability

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