Social and Behavioral Sciences Commons^™

Naturalistic Decision Making In After-Action Review Meetings: The Implementation Of And Learning From Post- Fall Huddles, Roni Reiter-Palmon, Victoria Kennel, Joseph A. Allen, Katherine J. Jones, Anne M. Skinner

Psychology Faculty Publications

The purpose of this study was to add to our understanding of naturalistic decision making (NDM) in health care 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, …