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.

Enid Rivera-Chiauzzi, MD

	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.

 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.

 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.

Related: Tort law and malpractice for the physician

	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.

 HROs have certain characteristics and tenets in common.

	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.

	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.

	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.”

	Most significant adverse outcomes will be reviewed in the quality improvement process, perhaps even reaching the level of a root-cause analysis. These are helpful tools for examining the most serious outcomes; however, near misses and less serious outcomes may not make it to this stage of review. Debriefing can be applied more broadly, serving as a first step to identify critical focus areas for frontline team members and guide further review.

	Extensive research has been done on 2 major debriefing techniques: non-judgmental debriefing and debriefing with good judgment. Rooted in adult learning theory, both approaches employ what has become known as the “sandwich technique,” which frames feedback by asking the following questions:

	3.     What lessons have been learned?

	The focus of non-judgmental is on the learner’s actions/inactions with the debriefer going out of his or her way to teach in the most positive way possible. Discussion of an error is “sandwiched” between positive impressions about what the learner did well.

 The downside is that this approach focuses so little on serious errors that the learner either feels that the error shouldn’t be discussed, or that it could be repeated with little consequence. This is likely not a message the learners should be taking home.

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	To build upon the positive elements of non-judgmental debriefing, debriefing with good judgment was developed. This method takes into account the assumptions, knowledge, and specific attitudes of both learner and debriefer. Instead of a teacher-student relationship, the sense is that the learner and debriefer are a team in the process. Phrases such as, “Help me understand why you…” promote a sense that both have perspectives affected by their personal knowledge and assumptions. Debriefing with good judgment allows the debriefer to address serious errors while maintaining learner integrity.

 The main goal is to create an environment conducive to learning from mistakes and changing clinical practice. This approach also focuses on systems that may promote error, and seeks solutions. Another technique that can be used in conjunction with either of the above is called plus/delta. In the plus/delta technique, two columns are drawn on a flip chart, one with a “+” and one with a “â” to list the positive behaviors and the areas for change. This method may help learner and debriefer to visualize take-away messages.

	Simulation-based medical education (SBME) has demonstrated benefits over traditional didactic education. This type of education allows practice of clinical skills for rare but critical events without a patient, which makes it a safer learning environment. Debriefing, as previously described, allows individuals and teams to complete three important tasks: “reflection, feedback, and future experimentation.”

 Debriefing’s role in simulation has been stated to “facilitate the transfer of new knowledge, skills, and attitudes to the clinical domain, primarily through enactment of the relocation stage of experiential learning and providing the opportunity for the experimentation aspect of adult learning.”

 All debriefing approaches and styles include 7 elements in the process that affect what the learners will gain

	Debriefing generally follows a natural conversation path, including 3 phases: descriptions, analogy/analysis and application. The debriefer’s goal is to facilitate discussion past the description phase.

 Debriefing goals after SBME can be predetermined and/or developed during the simulation. Facilitator involvement in this process depends on the experience of participants. Training may improve a facilitator’s ability to lead an effective debrief, and sites around the country offer formal training programs.

	The Debriefing Assessment for Simulation in Healthcare (DASH) is a published, validated tool developed to assess a provider’s performance in leading a simulated debriefing.

 The tool can be used to assess debriefer effectiveness even outside the simulated environment. Because it is not specialty-specific, the tool can be easily adapted across the healthcare system.

	Debriefing has been incorporated in several clinical fields, including critical care, surgery, internal medicine, and neonatology, although the focus remains on enhancing learning in SBME

 One interesting study, using data recorded during actual cardiopulmonary resuscitations (CPR), showed improvement in CPR skills among internal medicine residents who debriefed after the event.

	Surgery has perhaps done the most to implement debriefing as a routine step. With built-in opportunities throughout the course of a procedure to brief and debrief in order to attain the desired outcome of safe surgery, surgical teams may more easily adopt this practice.

 Although debriefing has been adopted in some fields, there remains little standardization of the process.

 Debriefing largely remains a powerful, yet underutilized tool throughout healthcare.

	Achieving high reliability is perhaps even more critical within obstetrics where the stakes are so high. The HRO tenet “preoccupation with failure” offers a useful framework for obstetrical units to improve outcomes.

 This tenet encourages culture change where teams and units celebrate near misses and spend time discussing and reviewing events in order to improve team and system performance.

 One way to achieve this type of culture is to incorporate debriefing (Table 2).

	A variety of healthcare organizations, professional societies, regulatory bodies and malpractice insurers have advocated for adoption of strategies, such as debriefing, which offer a standardized, effective, reproducible way of gathering information to identify and address systems issues.

 In obstetrics, a combination of several approaches has been suggested and implemented to improve patient outcomes with considerable success.

 In the “Consensus Bundle on Obstetric Hemorrhage,” the National Partnership for Maternal Safety recommends debriefing as a routine step after hemorrhage to help the team identify opportunities for improvement in teamwork, skills, and outcomes.

	Ideally the entire interdisciplinary team (obstetrics, nursing, pediatrics, and anesthesia) should participate. It is critical to gather as many involved team members as possible to ensure a complete perspective. In cases in which a serious adverse outcome occurs (death or severe injury), it may be helpful to enlist the social worker to help facilitate a discussion with the patient and/or family members.

Related: The perinatal episode of care model

What types of events should be debriefed?

	Obstetrical units may decide to debrief all deliveries or just certain trigger events. Benefits to debriefing all deliveries include the ability for team members to practice the skill regularly and avoidance of an association between debriefing and negative outcomes. For a normal, uncomplicated delivery, debriefing is straightforward and quick, whereas a complicated delivery will require a lengthier session. The drawback to starting with universal debriefing is that it may seem off-putting to teams who fear that it will “take too long” or that this is just another task to be completed. Getting team members to appreciate the value of debriefing is essential to successful implementation and maintenance of the skill. To this end, starting slowly may be best. Team members usually want to discuss significant adverse events, so formalizing the process by defining trigger events may be a more manageable initial goal.

	Debriefing should ideally happen as close to an event as possible to maximize the potential for information-gathering and identifying systems issues. Sometimes, due to staffing, logistics, or the need to give team members a chance to decompress, debriefings may be delayed for several days after the event and take place in a more formal setting.

	Regardless of the timing, debriefing must occur in a safe space where participants feel comfortable enough to express opinions and offer suggestions.

	Trained debriefers should be available in the initial phase of implementation to guide staff and model appropriate behavior during debriefing. This allows staff to learn how to debrief on their own. A debriefing guide may be utilized to assist staff .

 A deidentified form should document any systems issues uncovered and be submitted to a centralized team for follow up. Following up on identified issues, developing systems solutions and giving feedback to the team are crucial steps to assure the staff that debriefing is valuable and meaningful.

	The type of debriefing discussed here is generalized and more focused on identification of systems issues. There is another type of debriefing that is of equal importance after critical events: critical incident stress management (CISM).

 CISM is meant to be a comprehensive package of interventions intended to mitigate the impact of a traumatic event; facilitate recovery for people having normal reactions to a traumatic event; restore adaptive function for individuals, communities, or organizations; and identify people who could benefit from additional support services or referrals for further evaluation and treatment.

Next: Using simulation to develop surgical skills

	A full discussion of this type of debriefing is beyond the scope of this article; however, it is important to note that the debriefing described often serves as one mechanism for providing support to team members involved and identifying those who need additional resources. In some of the rarest and most severe events (death or serious injury), the more generalized, “fact-finding” debriefing may be delayed in favor of CISM as an immediate intervention to support affected staff.

	While there is no clear-cut answer to the question of legal protections for items discussed during a debriefing, it is important that hospitals collaborate and coordinate within existing quality and patient safety structures to ensure success. Variations in individual state law mandate that hospitals work closely with their legal departments to ensure any protections possible for debriefings.

 The fact that a debriefing occurred should only be seen as positive and evidence of a commitment to safety and continuous quality improvement. Hospitals should not forgo this important aspect of teamwork and communication for fear of legal ramifications.

	Incorporating debriefing into obstetrical care has the potential to transform the way teams function. While clearly an effective tool for promoting learning, reflection and system change, debriefing may also help to identify vulnerable team members whoe need further support after an adverse event.

	This low-cost, low-resource tool can be easily adapted to other fields within women’s health. We envision a standard, effective, reproducible, tangible debriefing method becoming a catalyst for transformative change.

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	4. Agency for Healthcare Research and Quality. TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety. Available at: http://teamstepps.ahrq.gov/.

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Experiential Learning: Experience as the Source of Learning and Development.

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Articles

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.

Enid Rivera-Chiauzzi, MD

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Debriefing after adverse outcomes: An opportunity to improve quality and patient safety