Rapid Response After-Action Review: Improving Patient Safety in a Military Hospital

Abstract

Problem: The after-action review is the military’s version of debriefing and a validated tool to elicit feedback, facilitate reflection, and improve processes. Failure to debrief results in missed opportunities to reflect on performance and use feedback to mitigate risk and prevent errors. The rate of after-action review completion following rapid responses on a 40-bed adult medical unit at a large military hospital is inconsistent, occurring less than 20% of the time. After-action review completion rates, inefficiencies, and poor data quality correlate with a lack of structure, the absence of a standardized tool, and facilitator training. Purpose: The purpose of this quality improvement project was to implement a standardized after-action review process post-rapid response using an electronic TeamSTEPPS debriefing tool. The goal was to improve after-action review effectiveness, completion rates, and patient safety. Methods: Implementation of the project occurred over 15 weeks. The rapid response team received facilitator training using the TeamSTEPPS Debrief Module, and unit staff received an overview of the task, purpose, and participation requirements. Goals and outcomes included total staff trained, completion rates using the tool, and patient safety events. Data were analyzed using descriptive statistics. Run charts visually displayed completion rates and associated patient safety reports. Results: The rate of after-action reviews conducted increased from 0% to 48.6% in fifteen weeks. Opportunities to improve clinical performance included communication, training, and resource availability. Patient safety events associated with rapid response events decreased by 75% for all inpatient units during implementation. Conclusions: Findings suggest rapid response after-action review completion rates increased by introducing a structured process and standardized electronic tool. After-action review data revealed opportunities to enhance team effectiveness and fill knowledge gaps to reduce patient safety events associated with rapid response activation.