Table 5 Quality assurance reporting from debriefings (n = 49)
Debriefing Report Type | Total number of relevant reports | Example(s) of group recommendation | Documented Practice Changes | Potential Outcomes |
|---|---|---|---|---|
Equipment failure or deficit reported | 20 (40.8%) | End-tidal Co2 not routinely available for transport of intubated patients | EMMA™ end tidal Co2 device added to transport packs | Redundancy built into transfer pack for intubated patients |
Targeted education required or recommended | 13 (26.5%) | Inappropriately low triage category Unfamiliarity with obstetric medications | Individual feedback and education by mentor Shortcuts available for rarely used medications | Reduced future risk of ‘undertriage” and increased team familiarity with medications |
Breach in standard operating procedure(s) or protocol(s) | 2 (4.1%) | Use of a LUCAS-3™ compression device (contraindicated in trauma) | Laminated guidelines attached to storage area and mechanical CPR device | Reduce risk of inappropriate use of devices in future cases |
Further debriefing opportunities organised | 2 (4.1%) | (Poor outcome (a premature neonate died in ED), noise level was a concern to some team members | Identified need to for formal emotional debriefing | Additional debriefs to provide psychological support for affected staff |
Other(s) | 12 (24.5%) | Massive Transfusion Protocol (MTP) unavailable on arrival | Patient medical record number and blood available pre-arrival | Reduce risk of MTP being delayed in future cases |