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Debriefing Policy (101.042)

Debriefing Policy (101.042) - Policies, Administrative, UWMF, UWMF-wide, Clinic Operations, Emergency Policies and Protocols

101.042


1
UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE

TITLE: DEBRIEFING POLICY

Effective Date: January, 2005 Approval: See Authorization
Supersedes: Major Medical Event Contact: Clinical Staff Education

Reviewed April 2007 April 2008 May 2009 May 2010 April 2011
September 2012 August 2013 February 2015

PURPOSE:

The purpose of this procedure is to provide a process to review, debrief and document a critical medical event
at any University of Wisconsin Medical Foundation (UWMF) or Department of Family Medicine (DFM) clinics.

DEFINITION:

1. Debriefing is a discussion with participants who were involved in and all relevant information relating to the
critical medical event.
2. Patient Safety Net (PSN) is an online program for documenting events and potential events (“Near Miss”) in
order to identify areas of system vulnerability and possible system enhancement.

POLICY:

Employees involved in the critical medical event will take part in a debriefing session. Employees are
excused from the debriefing if they are not scheduled to work the day the debriefing is held. Employees
excused from the debriefing may submit written information or questions regarding the event to the clinic
manager.

When possible, the Debriefing should be scheduled within 48 hours following the event.
* Please follow the “PSN and Debriefing - Flow Diagram” for guidance as to when to complete the PSN
or other incident reporting form, or if Debriefing should take place.

DEBRIEFING and PATIENT SAFETY NET (PSN)
A debriefing and PSN or other incident reporting form MUST be filled out for the following events:

ξ An EMERGENT life or limb-threatening event.
ξ Unusual occurrence or medical care given that produced an unexpected negative outcome.
ξ Emergency care rendered without the presence of a provider.
ξ The use of any Emergency Protocols found in the Emergency Procedure Manual.


PROCEDURE:

1. The clinic manager, supervisor or coordinator where the incident occurred will:
ξ Inform Operations Director and VP of Operations regarding the event.
ξ Coordinate / schedule debriefing (all departments involved).
ξ Arrange for a debriefing facilitator from Clinical Staff Education.
ξ Review PSN or other incident reporting form for accuracy and completeness within 72 hours.






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2. The debriefing facilitator, UWMF Clinical Staff Education Department, will:
ξ Review the completed PSN.
ξ Conduct the debriefing.
ξ Complete the Debriefing checklist.
ξ Scan/File completed Debriefing checklist into appropriate PSN event report.

3. The UWMF Emergency Procedure Work Group will:
ξ Review all related events.
ξ Establish benchmarking and quality improvement measures.
ξ Make recommendations for improvement.

If an Optional debriefing takes place a PSN or other incident reporting form will need to be completed:
Examples of an optional debriefing would include:

ξ A situation that may be new, unfamiliar, or complex or an unusual occurrence for the clinic.
ξ One in which all events went well, however, a situation in which the staff may feel a need to discuss
the event and its outcomes.


REFERENCE: American Heart Association Advanced Cardiac Life Support, 2014.

WRITTEN BY: Ronnie Peterson RN, MS, Manager of Clinical Support
REVISED BY: Ronnie Peterson RN, MS, Manager of Clinical Support
REVIEWED BY: UWMF Emergency Workgroup, 2015

AUTHORIZED BY: Richard Welnick, MD, Medical Director, Ambulatory Clinic Operations, UWMF
Sandra A. Kamnetz M.D., Vice Chair, Department of Family Medicine

______________________________________________________________________________
Medical Director, UWMF Date

_______________________________________________________________________________
Vice Chair, Department of Family Medicine Date