Obstetric Emergency Team Debriefing Form Patient label Remember

Obstetric Emergency Team Debriefing Form Patient label Remember: Debriefing is meant to be a learning experience and a way to address both human factors and systems issues to improve the response for next time. There is to be no blaming/finger-pointing. Date and time of event: ____________ Event: Stat C/S PE Seizure Shoulder Dyst. Location of event: ______________ Cardiac event Stroke Amniotic embolism Maternal code Transfer to ICU NICU code Other: _______________________ Who was present? (Name and role, check if present at debriefing) q ___________________________ __________________________ q ___________________________ __________________________ Thinking about how the obstetric emergency was managed, Identify what went well: (Check if yes) Identify opportunities for improvement: “human factors” (Check if yes) q Communication q Role clarity (leader/supporting roles identified and assigned q Teamwork q Situational awareness q Decision-making q Other: ___________________________________________________________ Identify opportunities for improvement: “systems issue” (Check if yes) q Equipment q Medication q Blood product availability q Inadequate support (in unit or other areas of hospital) q Delays in transporting the patient q Other: ______________________________

Obstetric Emergency Team Debriefing Form For identified issues, fill in table below Issue Actions to be Taken Person Responsible Ensure that your patient and family understands what happened and support is provided. Turn into the Nurse Clinician mailbox when completed. Submit a Safety Intelligence Report (PSN) if appropriate.

Patient label Obstetric Hemorrhage Team Debriefing Form Remember: Debriefing is meant to be a learning experience and a way to address both human factors and systems issues to improve the response for next time. There is to be no blaming/finger-pointing. Date and time of event: ____________ Criteria met: VD: 1 L blood loss Location of event: ______________ CS: 1. 5 L blood loss Administration of Blood Products Bakri B-Lynch Hysterectomy Other: ______________________ Was patient assigned a hemorrhage risk? Low Medium High Not done Volume of blood lost: _________ Method: QBL Visual estimation Both Who was present? (Name and role, check if present at debriefing) q ___________________________ __________________________ q ___________________________ __________________________ Thinking about how the obstetric emergency was managed, Identify what went well: (Check if yes) Identify opportunities for improvement: “human factors” (Check if yes) q Communication q Role clarity (leader/supporting roles identified and assigned q Teamwork q Situational awareness q Decision-making q Other: ___________________________________________________________ Identify opportunities for improvement: “systems issue” (Check if yes) q Equipment q Medication q Blood product availability q Inadequate support (in unit or other areas of hospital) q Delays in transporting the patient q Other: ______________________________

Obstetric Hemorrhage Team Debriefing Form For identified issues, fill in table below Issue Actions to be Taken Person Responsible Ensure that your patient and family understands what happened and support is provided. Turn into Nurse Clinician mailbox when completed. Submit a Safety Intelligence Report (PSN) if appropriate.