At the end of a resuscitation, everybody in the room has a slightly different account of what just happened and what it was. The nurse who drew the gas, the registrar who intubated and the consultant who arrived at minute six each hold a fragment, and nobody compares them before the room empties.
The fix takes twenty seconds. Before anyone leaves, say aloud: this is what I think is going on, this is what I am not sure about, and this is what would change my mind. Then ask whether anyone saw something that does not fit. The nurse who was at the head of the bed frequently has the detail that matters, and will not volunteer it unprompted to a senior colleague who sounds certain.
It also fixes the handover downstream. A working diagnosis stated with its uncertainty travels honestly; one stated flat becomes fact by the time it reaches the ward, and the person who could have corrected it has gone off shift.
- Say the working diagnosis, the uncertainty and the falsifier aloud before the team disperses.
- Ask directly whether anyone saw something that does not fit.
- Ask the person who was at the head of the bed; they hold details nobody else saw.
- Carry the uncertainty into the handover rather than flattening it into a diagnosis.
- Twenty seconds at the end of the resuscitation, not a formal debrief later.
Why it matters
The detail that would change the diagnosis is usually held by someone who will not volunteer it to a colleague who sounds sure.
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