Reflective Review

  • Team debrief
    • each team member contribute equally (measured by time talking)
    • reflect what worked well
    • share where there were areas for improvement
    • identify areas where communication was an issue
    • review of shared mental model and clinical knowledge
  • Full participation helps build the specific care team
  • Full participation improves team communications

Patient Impact

  • Playing the patient story (as identified by PSMF)
    • may be the entire patient video or in part
    • important for teams to understand the family impact on errors
  • Review of how the team incorporated information from patient or family members
    • accurate understanding of patient’s history
    • acknowledgement of patient and family fears
  • Communication with Patient and Family
    • Potential risks
    • Management of family members
  • Transparency with Patients and families when adverse event happens

Processes and Procedures

  • Review of existing processes and procedures
    • did they meet the operational needs
    • was there an impact to patient safety
    • was there unnecessary waste or time spent
    • proper resources
      • trained staff
      • medication
      • equipment
      • safeguards
  • Look for commonality of issues from week to week

see previous: Focused Simulation