Name
#183 A Culture of Debriefing: Building Teamwork and Trust through Technology and Transparency in After Action Reviews
Content Presented On Behalf Of:
USPHS
Session Type
Poster
Date
Tuesday, March 3, 2026
Start Time
5:00 PM
End Time
7:00 PM
Location
Prince Georges Expo Hall E
Focus Areas/Topics
Clinical Care, Technology
Learning Outcomes
1. Summarize the benefits of multidisciplinary review of debriefs or after-action reports.

2. Explain how project management programs can improve system task follow up and transparency for staff.

3. Describe the process used by Alaska Native Medical Center to improve the culture of debriefs in a Labor and Delivery unit.
Session Currently Live
Description

Background: It is best practice for clinical teams to debrief critical or emergent events after they happen to establish a shared mental model of what happened, reflect on their performance, learn what to do in the future, and identify system improvements to optimize patient care and safety. Debriefs, or After-Action Reviews, increase individual and team performance, psychological safety, and decrease adverse events and staff stress. It can be difficult for teams to engage in debriefs when they have competing priorities and they don’t see the system changes from debriefs. This poster describes the critical event debrief process at Alaska Native Medical Center’s Family Birthing Services unit, and key lessons learned to increase debrief participation. Method: We used a cloud-based project management tool to create a real time dashboard with feedback from submitted debrief forms. This gave staff an easily accessible, up-to-date way to see progress on the system changes they had suggested and to learn from other teams’ experiences through a “Pearls from You Peers” rotating slide show. “Pearls from your Peers” showcases lessons learned to improve individual or team performance that could be applied in a similar future event. Pearls from your Peers were updated on an every-other-month basis and were the only piece of the dashboard that required manual updating. All other aspects of the dashboard update automatically as team members submit work done on our leadership tracker form. The cloud-based project management tool simplified engagement of a multidisciplinary debrief review team, ensured clear delegation and follow up on system tasks, and identified trends or common issues to better inform staff education. The designed tool required minimal manual work to keep up to date. Results: After implementation, the number of debriefs from critical events increased 43%. The simulation committee and educators used information from debriefs to design education on 12 topics in 2024, including communication, transfusion reactions, rapid transfusion, and uterine inversion. There were 25 “Pearls from your Peers” or lessons learned shared on the dashboard over the course of 2024, which included themes around using closed loop communication, call outs, activating additional help early, and managing shoulder dystocia. There were 86 systems improvements addressed in 2024. For example, one commonly identified issue around quickly obtaining blood in an emergency was improved by creating a “pink box” order where every patient has orders for 2 units of cross-matched blood planned. This order can then be initiated by the nurse quickly when it’s needed, rather than keep a lot of blood on hold or resorting to emergency uncrossmatched blood unnecessarily. This project contributed to the IHS’ strategic plan for patient safety by creating capacity to manage patient and staff safety events while closing the loop between leadership and staff on process improvements.