Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.

… to establish the effectiveness of such initiatives. … Connolly W, Li B, Conroy R, et al. J Patient Saf.   Epub 2020 Dec 29. …

… decreases to national programs and guidelines.   … Connolly W, Rafter N, Conroy RM, et al. The Irish National Adverse Event Study-2 …

In this retrospective study, researchers sought to understand the frequency of adverse events across Irish hospitals in the context of recent financial constraints. Review of 1574 records from inpatient admissions revealed that adverse events occurred in approximately 12% of cases and contributed to significantly increased costs.

This study found that hospital pharmacist reporting of medication errors was influenced by behavioral norms, and senior pharmacists were more likely to report errors. These results emphasize the need to bolster safety culture to enhance reporting of adverse events.

This review explored patient transfer in hospitals to identify common areas for communication failures during handoffs.

This study describes the development and implementation of a medical student curriculum that focuses on patient safety principles and skills. Although the module was rated highly, participants pointed out the difficulty in translating the skills into practice.