Debriefing after adverse outcomes: An opportunity to improve quality and patient safety
When a case has unfortunate outcomes, obstetrical team members feel unsettled. Not only has an unanticipated, undesired outcome occurred for the patient and family, but team members also may question whether they did everything possible.
Dr Rivera-Chiauzzi is an Instructor, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York.
Ms Lee is the Maternal-Perinatal Patient Safety Officer, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York.
Dr Goffman is the Director, Quality, Patient Safety & Simulation and Associate Professor, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York.
A healthy woman presents to the hospital in labor. Her labor becomes protracted and the fetal heart rate tracing develops deep repetitive variable decelerations, consistent with Category II. An amnioinfusion is initiated; Category II tracing persists, leading to a decision for cesarean delivery. The patient is consented and transferred to the operating room. While en route, she becomes unresponsive and appears blue. A rapid response is called. The code cart is obtained; neonatal intensive care (NICU) and anesthesiology teams arrive. The patient’s oxygen saturation is 70% and a faint pulse is palpated. She is intubated and becomes pulseless. The team initiates a full resuscitation with chest compressions. An emergent cesarean delivery is performed. The infant is stabilized and transferred to the NICU. The patient’s uterus is boggy, and despite uterotonic medications and fundal massage, she has a massive postpartum hemorrhage. The massive transfusion protocol is activated. Bleeding is controlled; the patient is stabilized and transferred to the ICU.
When a case like this unfolds, obstetrical team members feel unsettled. Not only has an unanticipated, undesired outcome occurred for the patient and family, but team members also may question whether they did everything possible. Some teams don’t talk about incidents like these and move on to the next case, leaving unanswered questions. A better option is to gather the team as soon as possible to discuss the case in a non-threatening way so that everyone can learn, identify opportunities for systems improvements, and perhaps heal. This is known as debriefing.
Debriefing has been extensively utilized in other industries and has more recently been adapted for healthcare. It originated in the military, where soldiers returning from missions would discuss their experiences in order to learn and receive psychological support.1 Commercial aviation adopted Crew Resource Management in the late 1970s as a way to change the culture from one of hierarchy to one of high reliability and increased safety.2 In these 2 industries, debriefing is part of life, used as a way for team members to reflect on events, even routine ones, and to derive lessons to be applied in the future.
With the release of the 1999 Institute of Medicine report “To Err is Human,” which shed light on the abysmal numbers of deaths occurring in hospitals from preventable medical errors, a movement focused on patient safety began. With current estimates of preventable harm even higher, the patient safety movement has become more essential to healthcare’s future success.
When the healthcare industry embarked on its journey to high reliability, it looked to the military and aviation, which had been successful in achieving this difficult goal. High-reliability organizations (HROs) have systems in place allowing them to consistently accomplish goals while avoiding potentially catastrophic error.3 HROs have certain characteristics and tenets in common.3
To achieve high reliability, hospitals must adopt a culture of safety, which embraces errors and “near misses” as opportunities for learning and improving systems to avoid repeating the problem. The premise is that although providers are motivated to provide the best possible care for each patient, imperfect systems are often the root cause of errors. To achieve a culture of safety, hospitals must eliminate an atmosphere of fear and blame and move toward one of transparency, in which providers are encouraged to report errors and “near misses” without fear of punishment.3
Building upon the success seen in aviation, healthcare organizations began implementing crew resource management. Various team training programs exist in healthcare, although one of the most common is Team Strategies to Enhance Performance and Patient Safety (TeamSTEPPS), which was developed by AHRQ and the Department of Defense. TeamSTEPPS consists of 4 domains: communication, situation monitoring, mutual support and leadership. Teams are provided tools and strategies to assist members in becoming more effective and highly functional. As defined within TeamSTEPPS, debriefing is meant to be a brief, informal exchange and feedback session among team members that occurs shortly after an event designed to improve teamwork skills and outcomes. It is a key strategy within the leadership domain.4
Debriefing has the potential for tremendous impact on changing culture as it requires few resources and, when done effectively, can provide invaluable insight about systems issues. Recognizing this, in 2008, the Joint Commission issued a list of evidence-based practices and tips for effective debriefing and defined it as a process that “allow(s) individuals to discuss individual and team-level performance, identify errors made, and develop a plan to improve their next performance.”5
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