Implementation of a Clinical Event Debriefing Program in a Large Urban Tertiary Care Center

Area of Science:

• Healthcare Management
• Patient Safety
• Medical Education

Background:

• Clinical event debriefing (CED) improves provider wellness and patient care.
• Barriers to CED facilitation exist, often addressed by single-unit programs.
• Hospitalwide, multidisciplinary CED programs have not been previously described.

Purpose of the Study:

• To describe the implementation and maintenance of a hospitalwide CED program.
• To standardize CED conduct across multiple adult and pediatric departments.
• To address barriers and promote provider wellness and patient safety.

Main Methods:

• A three-pronged approach: multimodal facilitator training, a hospitalwide debriefing tool, and a multidepartment CED collaborative.
• Training improved provider comfort in facilitating CED.
• The collaborative reviewed documented CEDs to identify themes and inform practice solutions.

Main Results:

• Seventy providers completed training, showing significant improvement in facilitation comfort (p = 0.002).
• 309 CEDs were documented between July 2022 and July 2025.
• Recurrent themes in teamwork, communication, and systems processes were identified, leading to practice improvements.

Conclusions:

• A hospitalwide, multidisciplinary CED program is feasible and effective.
• The program enhances provider comfort and standardizes debriefing practices.
• Integration of training, a documented tool, and collaborative review supports sustainability and drives improvements.