1. The Effects of Debriefing Following Medical Error6
Results
The Effects of Debriefing Following Medical Error
Communication
The study conducted by Katheria et al. (2013) concluded that debriefing improves communication among healthcare providers which led to quicker response times to patient deterioration. Effective communication is directly linked to reduced medical errors, improved patient safety, and decreased patient mortality rates (Carney et al., 2010).
Team Approach
The common hierarchy approach to patient care actually may be more harmful than beneficial. Utilizing a team approach has been shown to be more effective in ensuring patient safety (Katheria et al., 2013). The study conducted by Weld et al. (2016) concluded that after implementing debriefing sessions, fewer mistakes were made, and the OR became a predictable work environment. (Weld et al., 2016).
Patient Safety
The study conducted by McElroy et al. (2014) implemented a report system for medical errors and found that debriefing was most effective in recognizing patient safety incidences. Debriefings improve team communication and improve patient safety resulting in improved practice.
Jaclyn Frankenberger
Advisors:
Elizabeth Aquino
Randi Singer
DePaul University 5 1
Methods
Background
Literature Search:
Databases: PubMed, CINAHL, Nursing & Allied Health Database (ProQuest)
The search was limited to English-language original research articles, ranging from 2013 to 2018
Key words: errors, debriefing, briefing
Inclusion criteria: Implementation of debriefing in the clinical setting
Exclusion criteria: student population, simulation setting, educational setting
Medical errors are inevitable, causing more than 100,000 deaths annually.
Lack of communication is one of the leading contributors to medical errors.
Perfectionism has become an expectation among healthcare professionals, including nurses.
Debriefing may be utilized to improve communication, reduce medical errors, and improve patient safety.
Table 1. Synthesis of the studies.
Source
Purpose
Method
Sample
Findings
Carney et al. (2010)
Improve patient care outcomes and staff member job satisfaction by applying crew resource management communication principles and associated checklist driven briefings and debriefings in the clinical setting.
Quantitative study to evaluate a voluntary and/or anonymous questionnaire following participation in training between August 2006 and June 2007 in order to see improved communication resulting in safer patient treatment.
2,461 participants in the first 34 consecutive learning sessions. 690 participants self-identified as surgeons.
The goals of implementing a preoperative checklist driven briefings and debriefings are to improve teamwork, communication, and safe patient care. Therefore, the implementation of debriefings was beneficial.
Katheria et al. (2013)
Improve communication and leadership during neonatal resuscitations by including briefing and debriefing into their resuscitation checklist.
Quantitative study to evaluate the first two years of using the checklist plus debriefings to determine the frequency and type of events that may interfere with patient care.
Sample size was 260 from March 2009 to November The sample size for the second review was 185 from November 2011 to May 2012.
The implemented checklist and debriefings improved overall communication and recognition of problems leading to an improvement of communication errors. During the second year of the study, communication improved significantly.
McElroy et al. (2014)
Implement clinician debriefing in efforts to reduce the rates of medical errors and patient safety incidences in the OR.
Quantitative study to track incidence reports via reporting systems and compare to safety incidents reported via implemented safety debriefing tool from April 1, 2010 to April 1, 2011.
Debriefings were conducted for every kidney transplant surgery from April 2010 to April There was a total of 467 kidney transplant surgeries where 325 surgeries were selected for debriefing. A total of 270 debriefing responses were then reviewed.
This study showed that less safety incidents were reported via reporting systems as compared to incidences reported during debriefings. The results showed a total of 334 patient safety issues of 270 debriefings. This study concluded that the clinician debriefing sessions captured significantly more patient safety issues resulting in improved patient outcomes.
Weld et al. (2016)
Evaluate patient safety and communication between healthcare personnel in the OR.
Quantitative study to evaluate and compare performance before TeamSTEPPS training from November 2012 to October 2013 and after TeamSTEPPS training from November 2013 to October 2014.
1481 cases using TeamSTEPPS and 1513 cases before TeamSTEPPS.
The overall rate of patient safety issues was 15.8% which then declined to 6.2% meaning that patient safety improved, and the implementation of postoperative debriefings were beneficial. 2
Purpose
The purpose of this integrative review of the literature is to examine how debriefing may have beneficial effects in the clinical setting to assist healthcare providers in decreasing medical errors. 7
Conclusion
Each of the focused studies reached the conclusion that improving communication and implementing a team-mentality work environment will reduce incidences jeopardizing patient safety.
Debriefing involves:
Evaluating medical errors
Providing specific feedback
Facilitating communication
Improving future performance
Utilizing debriefing will ultimately decrease medical errors and improve patient safety. 3
Research Question
How are the effects of debriefing beneficial in the clinical setting to decrease medical errors among healthcare providers? 4
Conceptual Framework
An integrative literature review was conducted using the Transtheoretical Model as a conceptual framework.
Precontemplation
Contemplation
Preparation
Action
Maintenance
Termination