An initial attempt to implement debriefings across
all northern California perinatal units was challenging.
When the facilitation of the debriefing
was assigned to individuals from multiple disciplines
such as the obstetricians, charge registered
nurses (RN) or primary RNs, the debriefings did
not occur. The original process proved to be unreliable,
many debriefings were missed, and documentation
was not completed. Delegating the debriefing
facilitator role to a representative from a
single discipline improved the reliability of critical
event debriefings.