Table 5.

Quality assurance reporting from debriefings (n = 49)

Debriefing Report Type	Total number of relevant reports	Example(s) of group recommendation	Documented Practice Changes	Potential Outcomes
Equipment failure or deficit reported	20 (40.8%)	End-tidal Co2 not routinely available for transport of intubated patients	EMMA™ end tidal Co2 device added to transport packs	Redundancy built into transfer pack for intubated patients
Targeted education required or recommended	13 (26.5%)	Inappropriately low triage category Unfamiliarity with obstetric medications	Individual feedback and education by mentor Shortcuts available for rarely used medications	Reduced future risk of ‘undertriage” and increased team familiarity with medications
Breach in standard operating procedure(s) or protocol(s)	2 (4.1%)	Use of a LUCAS-3™ compression device (contraindicated in trauma)	Laminated guidelines attached to storage area and mechanical CPR device	Reduce risk of inappropriate use of devices in future cases
Further debriefing opportunities organised	2 (4.1%)	(Poor outcome (a premature neonate died in ED), noise level was a concern to some team members	Identified need to for formal emotional debriefing	Additional debriefs to provide psychological support for affected staff
Other(s)	12 (24.5%)	Massive Transfusion Protocol (MTP) unavailable on arrival	Patient medical record number and blood available pre-arrival	Reduce risk of MTP being delayed in future cases