Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during the Event

Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during the Event

Abstract

Editor’s Perspective:

What We Already Know about This Topic:

• Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation.

What This Article Tells Us That Is New:

• Failure to debrief after critical events is common among anesthesia trainees and likely anesthesia teams. Communication breakdowns are associated with a high rate of the failure to debrief.

Background: Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. The authors’ objective was to understand barriers to debriefing, characterize quantifiable patterns and qualitative themes, and learn potential solutions through a mixed-methods study of actual critical events experienced by anesthesia personnel.

Methods: At a large academic medical center, anesthesiology residents and a small number of attending anesthesiologists were audited and/or interviewed for the occurrence and patterns of debriefing after critical events during their recent shift, including operating room crises and disruptive behavior. Patterns of the events, including event locations and event types, were quantified. A comparison was done of the proportion of cases debriefed based on whether the event contained a critical communication breakdown. Qualitative analysis, using an abductive approach, was performed on the interviews to add insight to quantitative findings.