How healthcare professionals can learn when things go wrong

Data shows that around one in ten patients in developed countries experience an adverse event in health care. Common sources of harm include medication errors, healthcare associated infections, unsafe surgical procedures, pressure ulcers, falls or other factors. At least half of these are preventable.

Events that lead to harm are often due to resource issues and the design of the environment. Common examples include inadequate skills mix available and “look-a-like, sound-alike” medicines. However, this does not make it less upsetting or stressful for staff, patients and their families.

Part of finding out and learning from what went wrong, and why, involves giving healthcare professionals the opportunity to come together and ask questions of themselves and their colleagues. At the same time, repeating and amplifying good professional practice cannot occur without considering what went well, and how to build on that success.

Without a proper structure for this reflection, however, there is a risk of blame, recrimination and fractured teams.

One of the main ways in which healthcare professionals can learn from these events is through after-action reviews (AARs), which are facilitated, reflective and non-hierarchical debriefs where groups can discuss: what did we expect to happen, what actually happened, why was there a difference and, of course, what have we learned? 

500 staff trained

Since 2018, the RCSI Graduate School of Healthcare Management (GSM) has trained up to 500 clinical and non-clinical healthcare staff as AAR facilitators across Irish health. This involved the use of an in-person simulation-based programme over two days, co-designed and funded by the HSE National Quality and Patient Safety Directorate (NQPSD), with professional actors involved in simulation-based training.  

In 2019, the RCSI and HSE formed a research collaboration, funded by the Health Research Board, Applied Partnership Award, to assess the implementation and effect of AAR at a hospital site.  

With the Covid-19 pandemic limiting opportunities for in-person learning, there was concern that vital educational opportunities from the AAR programme could be lost.  

As part of the Irish Safety Culture and After-Action Review Experience (iCAARE) study, Dr Siobhán McCarthy, lecturer at the GSM, spearheaded the co-design and creation of a series of four educational videos aimed at creating and spreading an awareness of AAR and AAR facilitation skills. The results are published in a new paper in the peer-reviewed journal BMJ Open Quality, titled 'Videos of Simulated After Action Reviews: A Training Resource to Support Social and Inclusive Learning from Patient Safety Events'.

The videos were informed by learning from in-person delivery, HSE guidance and existing video simulations from other industries.  

Debriefing methodology

At its simplest, AAR is a debriefing methodology with a specific structure, and can be used formally and informally, for serious or minor events, in healthcare or, indeed, many other professional settings in a range of industries. Although designed for patient safety management, McCarthy and her colleagues share that AARs can also be used in healthcare for positive or neutral events – any event such as a well-run conference or at the close of meetings. And because more goes right than goes wrong in medicine, AARs could be crucial in helping drive further adaptation and improvement in healthcare. 

While AARs may be standalone, they are intended to complement, not replace, investigations or other forms of review. They allow those involved in patient safety events to talk about what happened without fear of blame or recrimination – making them less intimidating and more focused on learning and changing. They can also help to overcome some of the common barriers to learning from mistakes and successes, including a lack of timely in-person social discussion.  

In November 2022, approximately 300 incidents were recorded on the National Incident Management System, which used the AAR methodology; 23% of which related to medication events, 17% to falls, and 17% exposure to viral hazards, including Covid-19. This suggests that RCSI’s research, education and training activities, and partnership approach with the HSE have had an impact on the rollout of the AAR approach in Irish healthcare.

As digital resources become ever more important in postgraduate education, they could form a valuable case study informing future teaching and practice.