Post-Obstetrical Event Debriefing: A Quality Improvement Project

Many national medical organizations recommend debriefing to improve team performance and communication. However, health centers may still lack interdisciplinary team-based debriefs after critical events leading to negative impacts on communication, team performance, and future patient outcomes. In obstetrics, emergencies can happen at any time and studies suggest that communication errors contribute to their continued existence. It is important that obstetrical staff learn from these emergencies to improve performance in the future and achieve effective communication to reduce the risk of patient harm. To improve team performance and communication, using quality improvement methodology, a standardized debriefing guideline was implemented on a high-risk labor and delivery unit at a large academic health facility. The intervention standardized what type of obstetric events to debrief, when to debrief them, and how to debrief them. The intervention provided debrief facilitator training and practical forms to guide the discussion. Results from the intervention included a 207% increase in debriefing occurrences and a significant change in the nurses’ perception of team performance. The intervention was well received by nurses and providers caring for patients on the unit and the standardization of a post-OB event debriefing guideline was accomplished.Doctor of Nursing Practic