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Nebraska Debrief Implementation Collaborative Toolkit

Patient Safety Improvement Tools

Overview

This toolkit is intended to support Nebraska hospitals in their efforts to use debriefs to improve quality and patient safety in healthcare delivery. It was developed as part of a Debrief Implementation Collaborative program that NCPS coordinated in partnership with the following organizations:

  • Bryan Health Rural Division 
  • CHI Health Nebraska, CAH Network 
  • Nebraska Perinatal Quality Improvement Collaborative
  • Nebraska Association for Healthcare Quality Risk and Safety
  • Nebraska Coalition for Patient Safety
  • Nebraska Hospital Association

Funding for the Debrief Implementation Collaborative was provided by the Nebraska Department of Health and Human Services, Division of Public Health Office of Rural Health, Flex Program.

Debriefs

What is a debrief?

A debrief is a specific type of team meeting in which members discuss, make sense of, and learn from a recent event in which they collaborated*

  • Briefs, huddles, and debriefs initiate the teamwork system.
  • Effective debriefs are conducted by a trained facilitator who uses a structured guide to ensure psychological safety and team reflection.
  • Structured debriefs may be generic or event specific and used by clinical and non-clinical teams to improve system outcomes.

*Scott C, Allen JA, Bonilla D, et al. Ambiguity and freedom of dissent in post incident discussion. Journal of Business Communication. 2013;50: 383– 402. http://dx.doi.org/10.1177/0021943613497054

Why should debriefs be used?

Teams use debriefs to make sense of and learn from an event. According to Battles et al*, sensemaking is "the active process of assigning meaning to ambiguous data."  Sensemaking is a conversation among members of an organization about an unexpected, novel or ambiguous event that is conducted by a trained facilitator.

  • Each team member brings their unique knowledge and experience of the event to the conversation.
  • A facilitator uses a structured process to help team members combine these unique perspectives into a new shared mental model of what happened.
  • Team members use this shared mental model to develop an action plan that decreases risks/hazards to individual patients and the system.
  • Evidence indicates that effective debriefs decrease the risk of repeat events for individual patients, improve system outcomes, and improve staff perceptions of safety culture.

* Battles JB, Dixson NM, Borotkanics RJ et al. Sensemaking of Patient Safety Risks and Hazards. HSR. 2006; 41 (Part II):1555-1575.

Click on the titles below to download the valuable resources in this toolkit!

Debrief Implementation Collaborative Webinars

Generic Debrief Guides

Structures to Plan and Standardize the Debrief Program

Event Specific Debrief Guides

Council On Patient Safety In Women’s Health Care Patient Safety Bundles

This collection of evidenced-based care bundles has been developed by and is available from the Council on Patient Safety in Women’s Health Care.

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