Reflective ReviewTeam debriefeach team member contribute equally (measured by time talking)reflect what worked wellshare where there were areas for improvementidentify areas where communication was an issuereview of shared mental model and clinical knowledgeFull participation helps build the specific care teamFull participation improves team communications Patient ImpactPlaying the patient story (as identified by PSMF)may be the entire patient video or in partimportant for teams to understand the family impact on errorsReview of how the team incorporated information from patient or family membersaccurate understanding of patient’s historyacknowledgement of patient and family fearsCommunication with Patient and FamilyPotential risksManagement of family membersTransparency with Patients and families when adverse event happens Processes and ProceduresReview of existing processes and proceduresdid they meet the operational needswas there an impact to patient safetywas there unnecessary waste or time spentproper resourcestrained staffmedicationequipmentsafeguardsLook for commonality of issues from week to week see previous: Focused Team Engagement see next: Team Engagements