Commentary Debriefing in the OR: a quality improvement project. Citation Text: Finch EP, Langston M, Erickson D, et al. Debriefing in the OR: A Quality Improvement Project. AORN J. 2019;109(3):336-344. doi:10.1002/aorn.12616. Copy Citation Format: DOIGoogle ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 13, 2019 Finch EP, Langston M, Erickson D, et al. AORN J. 2019;109(3):336-344. View more articles from the same authors. Debriefing has emerged as a strategy to enhance individual and team communication. This project report discusses an initiative to improve operating room processes through debriefings. The authors describe how coaches, a checklist, and application of the International Classification for Patient Safety enabled learning from the debriefing process. PubMed citation Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Finch EP, Langston M, Erickson D, et al. Debriefing in the OR: A Quality Improvement Project. AORN J. 2019;109(3):336-344. doi:10.1002/aorn.12616. Copy Citation Format: DOIGoogle ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Families as partners in hospital error and adverse event surveillance. March 8, 2017 Optimizing Pediatric Patient Safety in the Emergency Care Setting. October 19, 2022 Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020 Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022 Family safety reporting in hospitalized children with medical complexity. July 20, 2022 Effects of patient-, environment- and medication-related factors on high-alert medication incidents. May 28, 2014 Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018 Program access, depressive symptoms, and medical errors among resident physicians with disability. January 12, 2022 Care transition of trauma patients: processes with articulation work before and after handoff. February 16, 2022 Strategies to prevent healthcare-associated infections through hand hygiene. July 30, 2014 Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021 Crowding in the Emergency Department: Challenges for the Care of Children. March 15, 2023 Racial and ethnic disparities in common inpatient safety outcomes in a children's hospital cohort. August 16, 2023 Changes in medical errors after implementation of a handoff program. November 12, 2014 Improving safety and quality of care with enhanced teamwork through operating room briefings. July 23, 2014 Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital. October 5, 2011 Does teamwork improve performance in the operating room? A multilevel evaluation. March 3, 2010 Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. June 22, 2022 The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study. March 16, 2016 Preventing home medication administration errors. March 14, 2022 Outpatient opioid prescriptions for children and opioid-related adverse events. August 8, 2018 Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. November 30, 2016 A patient safety toolkit for family practices. April 25, 2018 ACGME duty-hour recommendations—a national survey of residency program directors. August 11, 2010 Complication rates of central venous catheters: a systematic review and meta-analysis. May 29, 2024 Surgical count process for prevention of retained surgical items: an integrative review. May 11, 2016 Methods for studying medication safety following electronic health record implementation in acute care: a scoping review. January 10, 2024 Extended work shifts and neurobehavioral performance in resident-physicians. March 10, 2021 Declaring uncertainty: using quality improvement methods to change the conversation of diagnosis. March 17, 2021 Using a machine learning system to identify and prevent medication prescribing errors: a clinical and cost analysis evaluation. December 18, 2019 Changes in prevalence of health care-associated infections in U.S. hospitals. November 14, 2018 Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety. March 15, 2023 Call me Ishmael: addressing the white whale of team communication in the operating room with labelled surgical caps at an academic medical centre. May 8, 2024 Reducing inappropriate outpatient medication prescribing in older adults across electronic health record systems. January 13, 2021 Physician task load and the risk of burnout among US physicians in a national survey. December 2, 2020 Medication-related clinical decision support alert overrides in inpatients. November 15, 2017 Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. January 19, 2011 Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center. February 20, 2008 Structural racism and the COVID-19 experience in the United States. July 7, 2021 Structural racism in behavioral health presentation and management. May 17, 2023 Compliance with central line maintenance bundle and infection rates. August 23, 2023 When to err is inhuman: an examination of the influence of artificial intelligence-driven nursing care on patient safety. August 2, 2023 Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project. December 10, 2008 Simulation-based training for patient safety: 10 principles that matter. March 26, 2008 Testing a classification model for emergency department errors. June 28, 2006 What are the critical success factors for team training in health care? August 5, 2009 Hospitalized patients' understanding of their plan of care. January 27, 2010 How different countries respond to adverse events whilst patients' rights are protected. September 27, 2023 Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia. March 8, 2023 A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors. June 27, 2018 Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. December 6, 2017 A typology of electronic health record workarounds in small-to-medium size primary care practices. August 21, 2013 Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. July 11, 2012 Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. May 23, 2012 Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. October 24, 2012 Development and testing of an objective structured clinical exam (OSCE) to assess socio-cultural dimensions of patient safety competency. December 17, 2014 Reducing inappropriate polypharmacy: the process of deprescribing. April 1, 2015 Creating a fair and just culture: one institution's path toward organizational change. October 10, 2007 Patient perspectives of patient–provider communication after adverse events. August 10, 2005 The Threats to Australian Patient Safety (TAPS) study: incidence of reported errors in general practice. August 2, 2006 Accuracy of practitioner estimates of probability of diagnosis before and after testing. May 5, 2021 The World Federation of Chiropractic Global Patient Safety Task Force: a call to action. June 19, 2024 The dollar or disease burden: caps on healthcare spending may save money, but at what "cost" to patients? March 2, 2021 The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system. May 25, 2022 Accuracy in patient understanding of common medical phrases. December 21, 2022 SAFER Care: improving caregiver comprehension of discharge instructions. March 31, 2021 Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. July 25, 2012 What did the doctor say? Health literacy and recall of medical instructions. May 16, 2012 Using social and behavioural science to support COVID-19 pandemic response. June 3, 2020 Helping patients simplify and safely use complex prescription regimens. March 16, 2011 Artificial intelligence in the provision of health care: an American College of Physicians policy position paper. June 12, 2024 Leading a highly visible hospital through a serious reportable event. April 25, 2012 Adverse medication events related to hospitalization in the United States: a comparison between adults with intellectual and developmental disabilities and those without. February 5, 2020 Medication errors recovered by emergency department pharmacists. July 14, 2010 Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery. January 13, 2010 A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system. December 16, 2009 Family alert: implementing direct family activation of a pediatric rapid response team. October 28, 2009 Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. March 27, 2005 Operational failures detected by frontline acute care nurses. March 29, 2017 Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. August 21, 2013 Communication disparities between nursing home team members. July 20, 2022 Learning from latent safety threats identified during simulation to improve patient safety. October 11, 2023 In their own words: safety and quality perspectives from families of hospitalized children with medical complexity. September 6, 2023 Judgment errors in surgical care. May 1, 2024 Parent participation in morbidity and mortality review: parent and physician perspectives. June 22, 2022 Errors in surgery: a case control study. December 14, 2022 I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting by trainees. August 25, 2021 Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU. November 30, 2016 A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care. September 21, 2016 Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review. November 22, 2017 Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. May 25, 2016 Four-year impact of an alert notification system on closed-loop communication of critical test results. November 26, 2014 Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence. February 26, 2020 Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services. August 14, 2019 Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme. August 18, 2010 Teamwork in healthcare: key discoveries enabling safer, high-quality care. July 11, 2018 National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. December 7, 2016 A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission. December 6, 2017 Information handoff and outcomes of critically ill patients transferred between hospitals. November 2, 2016 View More Related Resources Patient Safety Innovations Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle May 29, 2024 WebM&M Cases Failure to adhere to dietary restrictions leading to complications and poor follow-up. July 31, 2023 Understanding the root cause analysis process to increase safety event reporting. July 5, 2023 The role of an assistant nurse in implementing the WHO Surgical Safety Checklist: perception and perspectives. July 5, 2023 Patient Safety Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans May 31, 2023 Annual Perspective Improving Diagnostic Safety and Quality April 26, 2023 Guidelines in Practice: prevention of unintentionally retained surgical items. December 7, 2022 Preventing retained surgical items. August 3, 2022 Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis. November 24, 2021 Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery. September 22, 2021 WebM&M Cases Local Anesthesia-Induced Coma During Total Knee Arthroplasty. July 28, 2021 We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. March 17, 2021 Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist. May 8, 2019 Bringing perioperative emergency manuals to your institution: a "How To" from concept to implementation in 10 steps. April 3, 2019 Decreasing surgical site infections by developing a high reliability culture. February 6, 2019 Using good catches to promote a just culture and perioperative patient safety. December 12, 2018 Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. October 24, 2018 Guideline implementation: team communication. September 12, 2018 When bullying affects patient safety. July 25, 2018 Advances in perioperative quality and safety. June 13, 2018 A culture of civility: positively impacting practice and patient safety. April 25, 2018 Back to basics: the Universal Protocol. January 24, 2018 Enhancing pediatric perioperative patient safety. November 29, 2017 The checklist: recognize limits, but harness its power. November 22, 2017 WebM&M Cases Add-on Case and the Missing Checklist August 1, 2017 Enhanced time out: an improved communication process. June 21, 2017 Introductions during time-outs: do surgical team members know one another's names? May 24, 2017 Learning and mindfulness: improving perioperative patient safety. April 19, 2017 Promoting civility in the OR: an ethical imperative. March 8, 2017 Time-out: the professional and organizational ethics of speaking up in the OR. October 26, 2016 View More See More About The Topic Operating Room Nurses Nurse Managers Surgery Nurse Care View More
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022
Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020
Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022
Effects of patient-, environment- and medication-related factors on high-alert medication incidents. May 28, 2014
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018
Program access, depressive symptoms, and medical errors among resident physicians with disability. January 12, 2022
Care transition of trauma patients: processes with articulation work before and after handoff. February 16, 2022
Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021
Racial and ethnic disparities in common inpatient safety outcomes in a children's hospital cohort. August 16, 2023
Improving safety and quality of care with enhanced teamwork through operating room briefings. July 23, 2014
Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital. October 5, 2011
Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. June 22, 2022
The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study. March 16, 2016
Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. November 30, 2016
Surgical count process for prevention of retained surgical items: an integrative review. May 11, 2016
Methods for studying medication safety following electronic health record implementation in acute care: a scoping review. January 10, 2024
Declaring uncertainty: using quality improvement methods to change the conversation of diagnosis. March 17, 2021
Using a machine learning system to identify and prevent medication prescribing errors: a clinical and cost analysis evaluation. December 18, 2019
Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety. March 15, 2023
Call me Ishmael: addressing the white whale of team communication in the operating room with labelled surgical caps at an academic medical centre. May 8, 2024
Reducing inappropriate outpatient medication prescribing in older adults across electronic health record systems. January 13, 2021
Physician task load and the risk of burnout among US physicians in a national survey. December 2, 2020
Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. January 19, 2011
Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center. February 20, 2008
When to err is inhuman: an examination of the influence of artificial intelligence-driven nursing care on patient safety. August 2, 2023
Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project. December 10, 2008
How different countries respond to adverse events whilst patients' rights are protected. September 27, 2023
Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia. March 8, 2023
A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors. June 27, 2018
Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. December 6, 2017
A typology of electronic health record workarounds in small-to-medium size primary care practices. August 21, 2013
Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. July 11, 2012
Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. May 23, 2012
Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. October 24, 2012
Development and testing of an objective structured clinical exam (OSCE) to assess socio-cultural dimensions of patient safety competency. December 17, 2014
Creating a fair and just culture: one institution's path toward organizational change. October 10, 2007
The Threats to Australian Patient Safety (TAPS) study: incidence of reported errors in general practice. August 2, 2006
The World Federation of Chiropractic Global Patient Safety Task Force: a call to action. June 19, 2024
The dollar or disease burden: caps on healthcare spending may save money, but at what "cost" to patients? March 2, 2021
The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system. May 25, 2022
Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. July 25, 2012
Artificial intelligence in the provision of health care: an American College of Physicians policy position paper. June 12, 2024
Adverse medication events related to hospitalization in the United States: a comparison between adults with intellectual and developmental disabilities and those without. February 5, 2020
Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery. January 13, 2010
A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system. December 16, 2009
Family alert: implementing direct family activation of a pediatric rapid response team. October 28, 2009
Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. March 27, 2005
Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. August 21, 2013
Learning from latent safety threats identified during simulation to improve patient safety. October 11, 2023
In their own words: safety and quality perspectives from families of hospitalized children with medical complexity. September 6, 2023
Parent participation in morbidity and mortality review: parent and physician perspectives. June 22, 2022
I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting by trainees. August 25, 2021
Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU. November 30, 2016
A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care. September 21, 2016
Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review. November 22, 2017
Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. May 25, 2016
Four-year impact of an alert notification system on closed-loop communication of critical test results. November 26, 2014
Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence. February 26, 2020
Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services. August 14, 2019
Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme. August 18, 2010
National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. December 7, 2016
A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission. December 6, 2017
Information handoff and outcomes of critically ill patients transferred between hospitals. November 2, 2016
Patient Safety Innovations Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle May 29, 2024
WebM&M Cases Failure to adhere to dietary restrictions leading to complications and poor follow-up. July 31, 2023
The role of an assistant nurse in implementing the WHO Surgical Safety Checklist: perception and perspectives. July 5, 2023
Patient Safety Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans May 31, 2023
Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis. November 24, 2021
Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery. September 22, 2021
We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. March 17, 2021
Bringing perioperative emergency manuals to your institution: a "How To" from concept to implementation in 10 steps. April 3, 2019
Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. October 24, 2018