About debriefing in medicine, its course of action, and the transfer of the learning points, you can read here:
1. Clinical Cases Provide Many a Topic to Debriefing
1.1. Transport of a Patient in a Rescue Sheet
An ambulance and a doctor's car are dispatched to a patient who has noticed a hemiparesis and difficulty speaking one hour ago. The team quickly diagnoses a stroke, sets up an iv line, and alerts the nearest stroke unit. As dusk is falling, the team has to transport the patient in their ambulance, it is not possible to dispatch a helicopter to the scene anymore.
Now, the patient has to be carried downstairs in a rescue sheet by several of the team members. As the team is halfway between two floors, the light goes out. It takes a few seconds until the relative, who is also on her way downstairs, has reached the light switch. This was not the first call in the emergency medical service during which such an incidence has happened.
Why had it been forgotten to ask the relative to stay at the light switch? It is the cause of the mistake, which the team should elucidate during the debriefing.
Even though no one was hurt in this case, sudden darkness when carrying a patient is all but unperilous. If a patient is being artificially ventilated, the endotracheal tube can easily be disconnected from the ventilator, or the tube is pulled out of from the trachea altogether. This has been reported in one of the anonymous critical incident reporting systems years ago.
1.2. A Patient with a Seizure
In the bedroom, the team encounters a patient with convulsions in his bed. On his lips, there is foam and some blood,which indicates a bite into the tongue. Furthermore, the patient had wet himself. His wife is understandably upset and says that her husband has never had something like this before. The team uses midazolam to interrupt the seizure quickly.
As the team applies an iv line and measures the blood glucose level it turns out that the value is far too low. Thus, the hypoglycaemia had triggered the seizure. As the emergency physician explicitly asks the wife, the latter tells her that the patient suffers from diabetes, uses insulin and has to deal with fluctuating blood glucose levels. After the intravenous administration of glucose the patient awakens and is handed over in a stable condition in the hospital.
Would the team have been able to detect the cause and give glucose as a first and successful treatment if it had asked the wife about potential causes of seizures? How can a team distribute the workload to manage the examination and questions about the patient's past medical history at the same time?
During the debrifing, everyone involved states that he or she had not immediately thought of a potential blood glucose imbalance as the real problem, but that everyone will remember this case and from now on ask whether a diabetes is known.
Looking at these two examples with two totally different problems, we already realise, how much there is to learn and further develop through consequent debriefings after calls.
2. The Course of a Debriefing, a Useful Tool, Tricks and Tips
2.1. A Debriefing Consists of the Following Parts
A given order contributes to a constructive debriefing for everyone and assures that no relevant facts are left out. The following parts should be included:
- everyone gathers without cleaning and refilling the rescue vehicles at the same time
- discussion of all positive aspects
- consideration of all workflows and actions that need improvement
- agreement on future strategies to prevent mistakes
- if applicable, discussion about how the case should be passed on anonymously and how improvements should be worked out together with the whole staff
- naturally, great accomplishments should be steadied, as well as the reasons why they have been achieved
- the one leading the debriefing asks whether there are any other remarks or ideas
2.2. A Valuable Tool to Analyse Errors Systematically
The so-called London Protocol has been developed by the Imperial College of London in order to analyse adverse events systematically. The main focus is on the intense investigation of the root causes and the establishment of improvements. The protocol can also be used in a discussion which lasts for five to ten minutes, though. You can download it in several languages from the website linked above.
Already during our first analysis, we can take the following factors into our account, which, in the end, trigger an adverse event together:
- organisation and management culture
- contributory factors influencing practice
- care delivery problems, active failures
- defences and barriers which have failed in the particular case
2.3. Tricks and Tips for the Investigation of the Cause
If we really want to know something, we should ask our questions accordingly. Questions starting with the letter "w" are open questions, which leave our conversational partner all possibilites to answer. Examples include: "Whom have you told that?" "When did you apply the defibrillation pads?"
Following our question, we should wait patiently. The other one might be thinking intensively. We only disrupt this process if we ask a second question immediately, or reformulate our question. We just keep quiet until we receive a reply.
When our counterpart has answered our question, we may, of course, dig deeper in order to elucidate the root causes completely. In doing so, we don't want to expose anyone, but find out what all of us need to consider in the future.
If someone, for example, says "I thought that..." we should listen carefully, because now the background of actions comes to light.
3. Debriefing after Simulator Sessions and in Reality
3.1. Debriefing of Scenarios at a Simulator
It costs the participants a lot of courage to work through a scenario at a simulator as a team and to debrief it afterwards. Many of them, amongst them seasoned experts, feel exposed when the scenario is scrutinised using video recordings. The following items are important during such a debriefing:
- the participants are picked up at the simulator room and all sit down in a circle
- everyone should feel comfortable and may bring his or her coffee cup
- asking open questions, the instructors explore what the participants have noticed themselves
- the least experienced team member should start so that he or she doesn't merely agree with the experts' opinions and, perhaps, withholds important observations
- the participants should develop the crucial issues themselves, supported by the instructors
- as they go along, the instructors encourage the team first to evaluate what it has mastered superbly as it is vital to know, why these actions and decisions brought about success
- concerning the errors which have been noticed, why they have happened is explored extensively until it is clarified what has been the root cause
- not the visible mistakes are crucial, but their causes
- the team members work out solutions which truly can be transferred to the real workplace, supported by the instructors
- one of the team members summarises the important points once again
- as a conclusion, every participant may state his or her personal take home message
3.2. Debriefing after a Real Call
Teams in the emergency medical service should also debrief their everyday calls, at least those which were not plain routine jobs, or those which challenged the team. It should discuss errors and near errors in the same way as particularly successful calls. Many items resemble a debriefing session at the simulator:
- the team should be complete and form a circle
- this is either done at the rescue station after more complex calls, or directly at the end of a call, according to the circumstances
- the least experienced team member should bring his or her observations forward first
- the team should analyse well-managed actions and efficiently communicated items
- when discussing items which need improvement accusations are not constructive
- as is the case after a simulation exercise, the team should rather find the root causes for mistakes and near errors together and work on solutions for the future
- as a conclusion, the team summarises the important points and assures that no team member has further remarks, or ideas which have not been addressed yet
We will elucidate under item 5. how the team puts its results into action.
4. Obstacles to a Debriefing in the Daily Routine
4.1. Obstacles in the Emergency Medical Service
In the emergency medical service, the ambulance and the doctor's car regularly come from different rescue stations, as the area which is served can be quite large in rural surroundings. Here, it can prove difficult to hold a debriefing if the ambulance takes the patient to the hospital alone, or the doctor's car is dispatched to another call if the patient's condition allows for that.
After the call, one of the teams may be dispatched again quickly so that a debriefing isn't possible in this case either.
If one has collaborated with the team of a helicopter this team will transport the patient immediately and won't be available for a debriefing.
4.2. Obstacles in the Hospital
Teams in emergency rooms, as well as on ICUs and regular wards, and in the operating theatre are mostly very busy and have to tend to the next patient quickly.
Staff shortages aggravate the problem.
If interdisciplinary teams collaborate, for instance, anaesthesiologists and specialists who perform surgical procedures, a consensus as to how a debriefing is conducted needs to be reached first.
4.3. How Do We Integrate a Debrifing Despite All the Adversities?
Both in the emergency medical service and in the hospital it is of vital importance to raise the awareness of the necessity of a debriefing. Then, the ones involved need to work out a structure and to determine on what occasions they want to hold a debriefing.
At any workplace, it helps to keep the debriefings short and to work on the most important items stringently without lengthy digressions.
A short debriefing of only one or two items followed by a sustainable transfer of the result is better than no debriefing, or a long one without any results.
If there is an immediate next call, the ambulance team and the one on the doctor's car can hold their debriefing later at their rescue station if they are both based on the same one.
These approaches certainly don't offer an appropriate solution to all adversities, but they increase the number of debriefings.
5. How to Transfer Learning Points Successfully
5.1. Transfer Within the Team
Within our own department it is advantageous to anonymise the case and present it to as many coworkers as possible at an appointed time.
After this presentation, the employees ponder together how the mistake can be prevented in the future if the the team, which had been involved in the incident, has not proposed any solutions itsself yet. The employees also determine how to control the effect of their measures. Again, the ones involved can use the London Protocol.
5.2. Two Short Examples
A Second Medication Instead of Water for Injection Purposes
During a call, a blood-thinning medication had been diluted in a medication used to lower the blood pressure instead of water for injection purposes. The root cause was that the blood-thinning medication had been prepackaged together with the wrong vial. This package had been prepared according to internal guidelines (blood-thinning medication together with the water).
Staff reacted excellently. The team involved debriefed the incident and presented it to everyone after anonymisation. Of course, a solution was elaborated and put into practice.
In order to prevent such a packaging together with a second medication instead of water for injection purposes, since this incident only water in plastic phioles is used for packaging, whereas most medications come in glass vials.
Muscle Relaxants in a Swiss Operating Theatre
If one first administers a muscle relaxant in an awake patient accidentally, he or she will be paralysed, including all muscles necessary for breathing, while being fully conscious. Then, rapid anaesthetic induction and immediate ventilation are essential. It goes without saying that such an experience traumatises the patient.
Therefore, it is common practice in a Swiss operating theatre to draw muscle relaxants into five milliliter syringes only, whereas all other medications are never drawn into such syringes. Some doctors and their assistants take one further step and place muscle relaxants away from all other medications.
5.3. How to Let Others Profit from the Results
On the internet, there are platforms dedicated to certain specialties, on which near mishaps and erros can be reported to a broad audience anonymously. These platforms are called critical incident reporting systems, CIRS. On some of these, the case reports are commented, and strategies to prevent the discussed error are presented. One example is the NHS reporting system.
After this industrious investigation we should not forget the great achievements and their background. Rather, we should pass on the successes as learning opportunities and allow ourselves to be positively inspired.
6. The Next Two Blog Articles Belong Together
We need to prepare thoroughly for August. Then, we will concern ourselves with how someone known beyond CRM hasn't only overcome the posttraumatic stress disorder, PTSD, but also informs others about this and encourages them to deal with it openly in order to be able to heal successfully.
We will work on the topics posttraumatic stress, PTS, and posttraumatic stress disorder, PTSD, already in July so that it won't be too much ad once. What characterises the two of them? How do we tell them apart? What are the neurological basic principles, the symptoms and treatment options?
Author: Eva-Maria Schottdorf
Date: June 26th 2022
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