ArticleJournal of occupational and organizational psychology2015
Naturalistic Decision Making in After-Action Review Meetings: The Implementation of and Learning from Post-Fall Huddles.
Article in Journal of occupational and organizational psychology, 2015. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 16 papers.
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Who cites it
16 citing papers in PubMed.
- The Effect of Toolbox Trainings on Nursing Sensitive Quality Indicators: A Randomized Controlled Trial.Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing · 2025Trial
- Resident- and family-led huddles for collaborative care planning in long-term care: a feasibility study.Innovation in aging · 2025Article
- Making sense out of uncertainty: cognitive strategies in the child custody decision-making process.Frontiers in psychology · 2024Article
- Applying after-action reviews to child and family teams to improve mental health service linkage within child welfare services: a study protocol.Implementation science communications · 2023Article
- Huddles and their effectiveness at the frontlines of clinical care: a scoping review.Journal of general internal medicine · 2021Article
- Article
- A Reasonable Officer: Examining the Relationships Among Stress, Training, and Performance in a Highly Realistic Lethal Force Scenario.Frontiers in psychology · 2021Article
- Article
- Simulation exercises and after action reviews - analysis of outputs during 2016-2019 to strengthen global health emergency preparedness and response.Globalization and health · 2020Article
- Group and Organizational Safety Norms Set the Stage for Good Post-Fall Huddles.Journal of leadership & organizational studies · 2019Article
- The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project.BMC health services research · 2019Article
- Review of alternatives to root cause analysis: developing a robust system for incident report analysis.BMJ open quality · 2019Article
- Information sharing in interteam responses to disaster.Journal of occupational and organizational psychology · 2018Article
- Improving Safety in Health Care for Patients With Neurocognitive Disorders and High Risk of Falls.Focus (American Psychiatric Publishing) · 2017Article
- Improving the Understanding of Psychological Factors Contributing to Horse-Related Accident and Injury: Context, Loss of Focus, Cognitive Errors and Rigidity.Animals : an open access journal from MDPI · 2016Review
- Macrocognition: From Theory to Toolbox.Frontiers in psychology · 2016Article
Corrections and comments
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Authors and funding
5 authors.
Funding
Abstract
The purpose of this study was to add to our understanding of Naturalistic Decision Making (NDM) in healthcare, and how After Action Reviews (AARs) can be utilized as a learning tool to reduce errors. The study focused on the implementation of a specific form of AAR, a post-fall huddle, to learn from errors and reduce patient falls. Utilizing 17 hospitals that participated in this effort, information was collected on 226 falls over a period of 16 months. The findings suggested that the use of self-guided post-fall huddles increased over the time of the project, indicating adoption of the process. Additionally, the results indicate that the types of errors identified as contributing to the patient fall changed, with a reduction in task and coordination errors over time. Finally, the proportion of falls with less adverse effects (such as non-injurious falls) increased during the project time period. The results of this study fill a void in the NDM and AAR literature, evaluating the role of NDM in healthcare specifically related to learning from errors. Over time, self-guided AARs can be useful for some aspects of learning from errors.
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Registered trials
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