An Innovative Method to Debrief Critical Events (1.5 CH)

Authors: Lori Helms, DNP, RN, NPD-BC, CPAN, Lori Buzalewski, BSN, RN, CPAN, Michelle Pachuilo, BSN, RN, CPAN, Ariana Pilat, BSN, RN, CCRN, CGRN, Kimberly Reeser, MSN, RN, CAPA

Purpose:  To explore if cold debriefing, which by definition, occurs days to weeks following the critical event, addresses identified barriers to routine debriefing and results in instituting debriefing as standard practice in the perianesthesia division at the site hospital.
Design:  A qualitative descriptive design using case study reviews
Methods:  Seven critical events, meeting the criteria of a preproject list, were debriefed by the patient’s primary nurse using a cold debriefing method. Following the debriefing session, the nurse outlining the event, and the staff in attendance were asked to complete a short survey. Knowledge gained or education needed, suggestions for process improvements, and perceived safety of the environment, and feeling safe to provide feedback were assessed.
Findings:  Identified barriers were reduced with the institution of cold debriefing. An average of 33% of the working staff were able to attend at least one debriefing session, indicating the barrier of time may be diminished by using cold debriefing. Most staff and debriefers also felt the environment was safe, and feedback provided during the debriefing sessions resulted in identified needed education and process improvement measures.
Conclusions: Implementation of cold debriefing to share and examine information following a critical event may address common barriers, result in process improvement measures, and identify educational needs required by the perianesthesia staff.