If We Don’t Learn from Our Critical Events, We’re Likely to Relive Them: Debriefing Should Be the Norm

This issue of Anesthesiology includes “Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during the Event” by Alexander Arriaga et al.¹  This mixed-methods qualitative study reveals that when a communication failure occurs during a critical event, there is less likely to be a “warm” and “proximal” debrief (warm meaning in person, and proximal meaning soon after the event). The authors acknowledge that we do not know whether this significant relationship is causal. They theorize that it is often easier to talk about clinical aspects of a case than about interpersonal or communication issues. This is a reasonable conclusion to draw, through their abductive approach, based on interviews with residents who had recently been involved with critical events. However, we are not sure cause and effect can ever be confirmed via a robust study.

There is another possible explanation for the association: after a critical event in which the participants had negative interactions (which some of the “communication failures” may have been), they would prefer to avoid more conflict, or they are too emotional to talk with each other. Communication failures can lead to unsubstantiated assumptions about the actions and intentions of others; these misjudgments may be a barrier to further conversations. Whatever the reason, it seems sensible that, even in the absence of concrete evidence, engaging in debriefs is a potentially effective tactic in a relationship-building patient safety strategy.

The authors demonstrated that the overall incidence of debriefing after a critical event (even just a brief bare-bones discussion) between a resident and attending at their major teaching hospital, was low—only 49.4%. They advocate for better and more frequent conversations between anesthesiology residents and their attendings and that similar conversations be conducted among other anesthesia dyads and perioperative professionals. Indeed, we believe that having interdisciplinary team debriefings, including members of all involved role groups, is an essential step toward narrowing the patient safety gap that still remains despite equipment and system safety innovations over the last 40 years.

As faculty for interdisciplinary simulation-based team training, we have seen firsthand how debriefing conversations between participants evolve during the course of a learning day. Hearing the concerns and perspectives of other participants not only enhanced teamwork in subsequent scenarios but served as an invitation for others to safely share their own observations and frames. The process of having a personal, shared experiential learning discussion seemed to be as beneficial as any of the clinical points that were covered. Indeed, several of our faculty have received unsolicited emails from some learners about perceived changes in working relationships after participating in interdisciplinary simulations with debriefings; subsequent interactions with fellow learners were described as improved, more chatty, or more informational. Making perspectives transparent, through debriefings and other opportunities, has been shown in healthcare and other industries to enhance interdependence of different role groups, trust, and improved performance.^2–4  We can use shared learning from debriefs to normalize expressing different perspectives and concerns and to decrease barriers to speaking up about safety issues in the heat of the moment, when a future crisis is unfolding. Debriefs can also help enforce the value of individuals’ input and the expectation of shared safety priorities.

Any traumatic event can have a significant emotional effect on providers.⁵  The lack of an interdisciplinary system in place to discuss incidents soon after a critical event can negatively impact perioperative team members (the “second victim”) as well as the care of their subsequent patients (the “third victim”). When debriefing is delayed, an opportunity is lost for learning, and the chance of repeating the same error likely is increased. We believe that establishing and sustaining a multidisciplinary debriefing system immediately after a critical incident will improve relationships and culture, provide an opportunity to prevent future similar critical incidents from happening, and support our clinicians for improved patient and provider safety.

The study by Arriaga et al. illustrates the value and challenges of conducting a robust qualitative study. The investigators have done a commendable job in designing, implementing, and analyzing the study. Qualitative research is as, if not more, challenging than quantitative research. The techniques are rooted in the social and psychologic sciences. For topics like this one, they are the preferred research method. Some positive aspects of the study are their use of grounded theory, piloting to seek saturation for coding terms, assessing the reliability of the coding, and using an established tool for categorizing communication failures. There are also some key factors that limit the conclusions we can draw from the results; for example, they involved residents rather than the entire team and had no perspectives from the attendings about why they may have chosen not to debrief. We hope these investigators and others will dig more deeply into critical events and communication failures and tell us more about how they evolve so that we can be better at managing them.

Another striking strength of the study by Arriaga et al. is that the residents in their hospital felt safe, even enthusiastic, about participating in the interviews and seeking out opportunities to share their stories. Perhaps this was facilitated by the overt support of their departmental leadership; it was the departmental chairman who introduced the study and the interviewers to the residents and the rest of the department. It is a reminder to us that impacting safety culture both is dependent on enlightened leadership and is itself an opportunity for emerging leadership. With our long history of focus on patient safety and simulation-based education, elevating quality outcomes through shared interdisciplinary learning and improved communication via debriefings is an important leadership skill for anesthesiologists.

We strongly believe that routine debriefing after all critical events is the right thing to do. However, we acknowledge that there is not good evidence or experience for how best to do it. There is evidence that our debriefings, as they stand now, are not ideal: participants can be left feeling more personally responsible, blamed, depressed, and fearful.⁶  We have much to learn about how to make the debriefs safe, effective, and practical. There are many questions to be addressed: Which events should be debriefed? How can the logistics of assembling the team be implemented given the challenges of respecting the needs of other patients who are awaiting their care? How should the debrief be conducted? Who should lead it? What kind of training is needed for conducting debriefings after critical events (it has similarities to but has important differences from debriefings after simulations)? These and other questions can best be answered with research on this topic, perhaps much of it in the natural environment during real debriefings and also via simulation.

“Those who don’t learn from history are doomed to repeat it” (attributed to Winston Churchill in a rephrasing of a quote from George Santayana). Debriefing is a learning opportunity not to be wasted. If there were communication failures, that shouldn’t be an excuse not to talk about what happened; it’s a reason to talk and to improve our teamwork skills. Making interdisciplinary debriefs our expected norm will allow each staff member to have the opportunity to learn and to provide and seek support. By strengthening our connectedness, we can learn from what went well and what did not, provide safer care for future patients, and receive needed help. In the end though, whether we repeat history or not will depend on how we apply what we have learned.