Failure to debrief after anesthesia critical events tied to communication breakdowns

Editor's Note

Failure to debrief after critical events is common in anesthesia trainees and teams, and communication breakdowns are associated with the failure to debrief, this study finds.

Over a 1-year period at a large academic medical center, anesthesiology residents and some attending anesthesiologists were audited and/or interviewed about the occurrence and patterns of debriefing after critical events.

Of 89 critical events that were identified, the debriefing rate was 49%. Almost half of the events occurred outside the OR and included crisis events such as cardiac arrest and difficult airway, disruptive behavior, and critical communication breakdowns.

Events with critical communication breakdowns were strongly associated with not being debriefed (64.4% not debriefed in events with a communication breakdown vs 36.4% not debriefed in events without a communication breakdown).

Interview responses demonstrated that lapses in communication were tied to confusion that could inhibit or shape the discussions between the involved providers.