Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Post-event debriefings during neonatal care: why are we not doing them, and how can we start?


Post-event debriefings are a foundational behavior of high performing teams. Despite the inherent value of post-event debriefings, the frequency with which they are used in neonatal care is extremely low. If post-event debriefings are so beneficial, why aren’t they conducted more frequently? The reasons are many, but solutions are available. In this report, we provide practical advice on conducting post-event debriefing in neonatal care. In addition, we examine the perceived barriers to conducting post-event debriefings, and offer strategies to overcome them. Finally, we consider opportunities to foster a culture change within neonatal care which integrates debriefing as standard daily work. By establishing a safety culture in neonatal care that encourages and facilitates effective post-event debriefings, patient safety can be enhanced and clinical outcomes can be improved.

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Rent or buy this article

Prices vary by article type



Prices may be subject to local taxes which are calculated during checkout

Figure 1


  1. Mullan P, Kessler D, Cheng A . Educational opportunities with post-event debrief. JAMA 2014; 312 (22): 2333–2334.

    Article  CAS  Google Scholar 

  2. Fanning RM, Gaba DM . The role of debrief in simulation-based learning. Simul Healthc 2007; 2 (2): 115–125.

    Article  Google Scholar 

  3. Tannenbaum SI, Cerasoli P . Do team and individual debriefs enhance performance? A meta-analysis. Hum Factors 2013; 55: 231–245.

    Article  Google Scholar 

  4. Mitchell JT, Everly GS Jr . The scientific evidence for critical incident stress management. JEMS 1997; 22 (1): 86–93.

    CAS  PubMed  Google Scholar 

  5. Everly GS Jr . A primer on critical incident stress management: what's really in a name? Int J Emerg Ment Health 1999; 1 (2): 77–79.

    PubMed  Google Scholar 

  6. Savoldelli G, Naik V, Park J, Joo HS, Chow R, Hamstra S . Value of debrief during simulated crisis management: oral versus video-assisted oral feedback. Anesthesiology 2006; 105 (2): 279–285.

    Article  Google Scholar 

  7. Morgan P, Tarshis J, LeBlanc V, Cleave-Hogg D, DeSousa S, Haley M et al. Efficacy of high-fidelity simulation debrief on the performance of practicing anaesthetists in simulated scenarios. Br J Anaesth 2009; 103 (4): 531–537.

    Article  CAS  Google Scholar 

  8. Falcone R, Daugherty M, Schweer L, Patterson M, Brown R, Garcia VF . Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation. J Pediatr Surg 2008; 43 (6): 1065–1071.

    Article  Google Scholar 

  9. Dine C, Gersh R, Leary M, Riegel B, Bellini L, Abella B . Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debrief. Crit Care Med 2008; 36 (10): 2817–2822.

    Article  Google Scholar 

  10. Sawyer T, Sierocka-Castaneda A, Chan D, Berg B, Lustik M, Thompson M . Deliberate practice using simulation improves neonatal resuscitation performance. Simul Healthc 2011; 6 (6): 327–336.

    Article  Google Scholar 

  11. Barry J, Gibbs M, Rosenberg A . A delivery room-focused education and deliberate practice can improve pediatric resident resuscitation training. J Perinatol 2012; 32 (12): 920–926.

    Article  CAS  Google Scholar 

  12. Sawyer T, Sierocka-Castaneda A, Chan D, Berg B, Lustik M, Thompson M . The effectiveness of video-assisted debrief versus oral debrief alone at improving neonatal resuscitation performance: a randomized trial. Simul Healthc 2012; 7 (4): 213–221.

    Article  Google Scholar 

  13. Cordero L, Hart B, Hardin R, Mahan JD, Nankervis CA . Deliberate practice improves pediatric residents' skills and team behaviors during simulated neonatal resuscitation. Clin Pediatr (Phila) 2013; 52 (8): 747–752.

    Article  Google Scholar 

  14. Sawyer T, Leonard D, Sierocka-Castaneda A, Chan D, Thompson M . Correlations between technical skills and behavioral skills in simulated neonatal resuscitations. J Perinatol 2014; 34 (10): 781–786.

    Article  CAS  Google Scholar 

  15. Edelson DP, Litzinger B, Arora V, Walsh D, Kim S, Lauderdale DS et al. Improving in-hospital cardiac arrest process and outcomes with performance debrief. Arch Intern Med 2008; 168 (10): 1063–1069.

    Article  Google Scholar 

  16. Jiang C, Zhao Y, Chen Z, Chen S, Yang X . Regular feedback learning from real-time video recording improved the quality of major CPR variables. Resuscitation 2010; 81 (12): 1664–1669.

    Article  Google Scholar 

  17. Wolfe H, Zebuhr C, Topjian AA, Nishisaki A, Niles DE, Meaney PA et al. Interdisciplinary, post-event quantitative debrief program significantly associated with improved cardiopulmonary resuscitation quality, and survival with favorable neurologic outcome. Crit Care Med 2014; 42 (7): 1688–1695.

    Article  Google Scholar 

  18. Nadler I, Sanderson PM, Van Dyken CR, Davis PG, Liley HG . Presenting video recordings of newborn resuscitations in debriefs for teamwork training. BMJ Qual Saf 2011; 20 (2): 163–169.

    Article  Google Scholar 

  19. Bhanji F, Mancini ME, Sinz E, Rodgers D, McNeil M, Hoadley T et al. Part 16: education, implementation, and teams: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122 (18 Suppl 3): S920–S933.

    Article  Google Scholar 

  20. Edwards E, Soll R, Ferrelli K, Morrow K, Suresh G, Celenza J et al. Identifying improvements for delivery room resuscitation management: results from a multicenter safety audit. Matern Health Neonatol Perinatol 2015; 1: 2.

    Article  Google Scholar 

  21. Kessler D, Cheng A, Mullan P . Debrief in the emergency department after clinical events: A practical guide. Ann Emerg Med 2015; 65 (6): 690–698.

    Article  Google Scholar 

  22. Salas E, Klein C, King H, Salisbury M, Augenstein JS, Birnbach DJ et al. Debriefing medical teams: 12 evidence-based best practices and tips. Jt Comm J Qual Patient Saf 2008; 34 (9): 518–527.

    Article  Google Scholar 

  23. Sandhu N, Eppich W, Mikrogianakis A, Grant V, Robinson T, Cheng A . Post-resuscitation debrief in the pediatric emergency department: a national needs assessment. CJEM 2013; 15 (0): 1–10.

    Google Scholar 

  24. Mullan P, Wuestner E, Kerr T, Christopher D, Patel B . Implementation of an in situ qualitative debrief tool for resuscitations. Resuscitation 2013; 84 (7): 946–951.

    Article  Google Scholar 

  25. Phrampus P, O’Donnell J . Debriefing using a structured and supported approach. Levine A, DeMaria S, Schwartz A, Sim A. The Comprehensive Textbook of Healthcare Simulation. 1st edn Springer: New York, NY, USA, 2013; 73–85.

    Chapter  Google Scholar 

  26. Cheng A, Rodgers D, Van Der Jagt E, Eppich W, O’Donnell J . Evolution of the Pediatric Advanced Life Support Course: enhanced learning with a new debriefing tool and web-based module for pediatric advanced life support instructors. Pediatr Crit Care Med 2012; 13 (5): 589–595.

    Article  Google Scholar 

  27. Kattwinkel J . Textbook of Neonatal Resuscitation. American Academy of Pediatrics and American Heart Association: Elk Grove Village, IL, USA, 2011 6th edn.

    Google Scholar 

  28. Training Circular 25-20, A Leaders’ Guide to the After-Action Review, Headquarters, Department of the Army, Washington DC. 30 September 1993.

  29. Sawyer T, Deering S . Adaptation of the U.S. Army’s After-Action Review (AAR) to simulation debrief in healthcare. Simul Healthc 2013; 8 (6): 388–397.

    Article  Google Scholar 

  30. McDonnell LK . Facilitation techniques as predictors of crew participation in LOFT debriefings. NASA Contractor Report; 196701 1996; 1–36.

  31. Apollo 13: The NASA Mission Reports. Vol 2. Burlington, Ontario, Canada: Apogee Books; 2000.

  32. Halamek LP . The genesis, adaptation, and evolution of the Neonatal Resuscitation Program. NeoRev 2008; 9 (4): e142–e149.

    Article  Google Scholar 

  33. Eichenwald E, Strand M . NRP Instructor Update Fall/Winter. American Academy of Pediatrics/American Heart Association 2015; 24 (2): 1–10.

    Google Scholar 

Download references


LPH is supported in part by the Endowment for the Center for Advanced Pediatric and Perinatal Education (CAPE).

Author information

Authors and Affiliations


Corresponding author

Correspondence to T Sawyer.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sawyer, T., Loren, D. & Halamek, L. Post-event debriefings during neonatal care: why are we not doing them, and how can we start?. J Perinatol 36, 415–419 (2016).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:

This article is cited by


Quick links