Debriefs help make sense of adverse events

Two teaching hospitals enabled clinicians and staff to discuss serious adverse clinical events soon after they happen.

Where: Delaware-based Christiana Care Health System Inc., which has 2 teaching hospitals in Newark and Wilmington with a total of more than 1,100 beds.

The issue: Enabling clinicians and other staff to discuss serious adverse clinical events soon after they occur.


When an adverse event happens during a patient's hospitalization, an emotional ripple percolates to clinicians and other staff members. “As humans, we are fallible, and we really own these events. When something happens, it's our obligation to bring it forward, raise our hand, and then to learn from it and share the learnings from it, change our systems, and then go further and make changes within the entire organization,” said Kathleen McNicholas, MD, JD, medical director of performance improvement at Christiana Care.

To systematically work toward this goal, Christiana Care launched a debriefing process in June 2009, formally designating the postevent period as a time to find the facts and implement improvements.

How it works

Debriefs are usually at least an hour in length and occur anywhere from 24 to 72 hours after the event. “Primarily, they're gathering the facts and what happened, and that's where the learning and the understanding come in,” said Michele Campbell, RN, MSM, vice president for patient safety and accreditation.

Depending on where the event occurs and who was involved in the patient's care, the debrief gathers related staff members from across the health system's 9 service lines. “A lot of these events are not just about 1 department or 1 service line because of the way care is delivered,” Ms. Campbell said. “You have the attending physician, but you have the specialists caring for the patient as well, so we do look at that horizontal work, not only vertical.”

Dr. McNicholas said the debriefing process is the antithesis of the ABC technique she often experienced as a cardiac surgeon—assess, blame, and crucify. “It is not an inquisition; it's a very supportive environment....I think people come in very nervous, in large part because it's something that's unknown to them, but we also want to hear everybody speak, so we start out introducing everybody in a friendly environment,” she said.


Christiana Care has now held more than 200 debriefs covering a range of issues, such as medication errors, patient falls, and unanticipated deaths, and has seen favorable patient safety results. For example, preventable patient harm (e.g., hospital-acquired infections, non-ICU code blues, and several other safety indicators) decreased by 60% from 2010 to 2014, according to an article published in January by The Joint Commission Journal on Quality and Patient Safety.

The debriefs have led to process improvements in several domains. For instance, the health system changed its approach to airway codes by creating airway carts with standardized supplies and assigning multiple trauma disciplines to respond immediately in case a surgical airway is needed, Ms. Campbell explained. In addition, special badges now allow clinicians to call for a code team without having to leave the patient and go to a phone. “We deployed the badges in areas where staffing was not as optimal as it could be on, say, the night shift or some of the remote labs,” Ms. Campbell said.


Scheduling debriefs that involve 10 to 20 people can be a challenge, especially when busy physicians need to be at the table, but there are workarounds, Dr. McNicholas said. “If we make it a 6 a.m., everybody comes because the only excuse, really, is that they like to sleep. And nobody wants to miss it because it is a deep and supportive discussion.”

Another challenge is that debriefs and the preceding adverse events can cause uneasiness among residents, so sometimes it's helpful to curtail the visibility of senior leadership at the meeting and minimize open, emotionally charged conversation, Ms. Campbell said.

“When anyone is intimately involved in that particular event...those individuals are hurting because they are the second victim, and we need to be hypersensitive to that fact because they may walk out and feel differently than what we're thinking they're feeling,” she said. “There have been instances where residents have felt uncomfortable, but if that comes up, we do try to [address] that outside of the debrief because not everybody feels comfortable talking about it.”

Next steps

Compared to when the debriefs first started, the criteria that necessitate a debrief have narrowed a bit to include only the more substantial events that involve patient harm, Ms. Campbell said. In less serious circumstances, unit-based care teams will often engage in more informal, immediate huddles instead.

Looking forward, both Ms. Campbell and Dr. McNicholas, who currently facilitate the debriefs, anticipate that the program will continue, although they are beginning to think about succession planning. “Certainly, I think when the leadership is engaged, that promotes change in culture as well as the process,” Ms. Campbell said. “I'd like to see more physicians who would be able to step in and be a facilitator among the service lines.”

Words of wisdom

“This takes a lot of courage. This is not for the faint of heart...[but] it is driven by empathy because we all [can] see ourselves in the role of the person who got caught at the sharp end and, particularly, in the role of our patients, who someday could be us,” Dr. McNicholas said.