The effect of after action review in enhancing safety culture and second victim experience and its implementation in an Irish hospital

After Action Review is a discussion of an event with the team involved in the event. Four questions are asked:

  1. what did we expect to happen?
  2. what actually happened?
  3. why was there a difference?
  4. and what have we learnt?

An independent person guides the process. The purpose is to help teams to learn together and to identify improvements. After Action Review is part of the Health Service Executive’s (HSE) Incident Management Framework (2018). It is one of a number of tools for reviewing events soon after they have occurred. These events (also called patient safety incidents) may have harmed patients, or did not cause harm but had the potential to. After Action Reviews can also be performed for events with positive outcomes.

In the United States (US), After Action Review has been used after disaster events to help learning about
responses to emergencies. It has been linked to improved safety culture in the US fire-fighting sector. However the impact of After Action Review in healthcare is not known. It is also not known how After Action Reviews are being used in Irish hospitals.

We plan to train staff from an Irish hospital in After Action Review. We will study how After Action Review is implemented over a year and ask staff their views on the safety culture in their hospital and whether they felt supported if they were involved in a patient safety incident. We will collect information on what helped the reviews happen and if there were any barriers and the financial costs. Study results will inform decision making about how to best incorporate After Action Review into Irish hospitals

Award Date
27 March 2020
Award Value
Principal Investigator
Dr Natasha Rafter
Host Institution
APA Cycle 2 2019