Patient safety is far too often threatened by unidentified system flaws, poor practices, weaknesses in team communication and lack of appropriate action after critical events. This has been highlighted by the Francis Inquiry, Morecambe Bay Investigation and Andrews Report.

 

The relevance of a culture of safety and communication is emphasized by the human factors and patient safety review published by the World Health Organisation in 2009. It advocates debriefing, a process of formally reflecting on own performances after a particular task, shift or event. It can enhance safety by learning lessons from both well managed and poorly managed events (Dismukes & Smith, 2000).

 

A structured approach to debriefing is used in a number of fields, including aviation and the military. However, in healthcare there is only limited use of debriefing tools in specific contexts (e.g. DISCERN post-resuscitation). Recent meta-analyses (Couper 2013, Tannenbaum 2013) support the use of clinical feedback and debriefing to improve performance. There are also beneficial effects of structured debriefing after planned learning events in the context of simulation-based and specific clinically centred educational exercises (SHARP, Ahmed 2013 and DEBRIEF, Sawyer 2013).

 

We designed the TALK© framework in June 2014. After a thorough literature review we have found no evidence of a widely applicable tool such as TALK© designed to guide structured team self-debriefing after unplanned learning events in clinical environments.