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Post hot debrief and incident review

Western NSW Local Health District

A hot debrief is a lessons learned review carried out immediately after the event to ensure all feedback, outcomes and actions required are obtained before anyone leaves. Minor details aren't lost because of time delay, or a later emphasis on the bigger issues.

Service targeted

Acute mental health inpatient units within a large WNSWLHD facility where mental health and generalists are co-located.

How was the project embedded within practice?

In response to an increase in restrictive interventions, this project was started to review practice. A review occurred of all seclusion and restraint instances focusing on the unit’s acuity, repeated instances with specific consumers and the identified clinical practice.

Staff who used restrictive practices more frequently were trained with alternatives to improve care delivery. Senior staff offered one-on-one support and further assisted in exploration with the clinician to identify what could have been done differently.

Hot debriefs directly take place following an event led by senior staff. During hours, the deputy director of nursing (mental health) attends. After hours, campus managers attend. This is to provide leadership and support to staff whilst promoting enhanced service accountability.

The purpose of the hot debrief is to explore the incident to understand what led up to the incident, involve consumers in discussions and to further identify clinical practice improvement opportunities.

What worked well?

  • Data collection and analysis of quality reports reported reduced rates in seclusion and restraint.
  • Leadership engagement ensured hot debrief and incident review were focused priorities. All the nursing unit managers were engaged and with the release of the recommendations from the Review of Seclusion, Restraint and Observation of Consumers with a Mental Illness in NSW Health Facilities the impetus to change was solidified.2
  • Clinical staff were supported to collaborate with the consumer, increasing choice in interventions and highlighted collaborative therapeutic care is possible at all stages of a consumer’s recovery journey.
  • Clinical staff felt validated and supported post-event, leading to positive overall unit environment.

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