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

A clinical event debriefing (CED) is a brief discussion among team members following a critical event. Despite the significant benefits of CED, including improving provider wellness and patient care, many barriers have been identified to facilitation. CED programs in single hospital units have been designed to minimize these barriers. Implementation of a multidisciplinary hospitalwide CED program including pediatric and adult departments has not previously been described. The authors describe the implementation and maintenance of a hospitalwide CED program developed to standardize the conduct of a CED across multiple departments.

The hospitalwide CED program was implemented through a three-pronged approach. First, the study team created a multimodal training available to all clinical providers to learn how to facilitate a CED. Second, a hospitalwide post-event debriefing tool was distributed. Third, the authors formed a multidepartment CED collaborative that reviewed documented CEDs and assisted with practice solutions.

Seventy providers across adult and pediatric departments completed facilitator training, with significant improvement in self-reported comfort facilitating CED (median 2/5 pre-training vs. 4/5 post-training, p = 0.002). From July 2022 to July 2025, 309 CEDs were documented. The CED collaborative identified recurrent themes in teamwork, communication, and systems processes informing departmental practice solutions.

A hospitalwide, multidisciplinary CED program is feasible and improves provider comfort with facilitation while standardizing debriefing practices. Integration of structured training, a scripted tool with documentation, and a collaborative review process support sustainability and drive practice improvements across departments. A framework to implement and sustain a CED program, while mitigating barriers, is described here.