Commit to a post-incident debrief loop
Create a specific commitment to run a short debrief after a care incident or near miss.
Make a short post-incident debrief a real management habit. A care incident, near miss, family escalation, or safety interruption has just happened and the team is about to disperse. If [incident or near miss trigger] happens, then before [handoff or shift end] I will gather the involved staff for five minutes and ask: what happened, what helped, what almost failed, and what changes before the next shift. Check whether the debrief happened, whether one action changed, and whether the next shift was informed. A resident almost falls during a rushed transfer but is steadied in time. A confused resident reaches…
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