The ED Grand Rounds

ED Grand Rounds is a weekly, multidisciplinary, practice-focused forum to improve decision-making, teamwork, and safety culture in the Emergency room, and strengthen the care delivered in real life — beyond textbooks, protocols, and routine lectures.

Rather than repeating academic content already covered in MEM, IMT and EMS teaching programs, ED Grand Rounds focuses on the non-technical competencies that determine patient safety, clinical reasoning under uncertainty, communication, teamwork, escalation, and system learning. 

• Real ED case from last week (frontline → doctor → M&M → teamwork demo)

• Non-punitive, Just Culture, behaviour-focused

• One takeaway + one action item captured weekly

Emergency medicine failures rarely occur due to a lack of knowledge. They occur due to missed cues, poor communication, delayed decisions, and team breakdowns. ED Grand Rounds exists to address exactly that. It is not about what we know. It is about how we think, how we act, and how we improve — together. 

ED Grand Rounds = (Improve) Decision making + Teamwork +  Safety culture

Quick facts:

• When: Wednesdays 8:30 AM

• Where: Academic Hall, Aster MIMS Kottakkal

• Format: 90 min | time-boxed

• Attendance: Google Form submission

• Live Zoom broadcast to satellite centres

• Structured, time-bound, and participation-driven

Why ED Grand Rounds Exists

Most adverse events in emergency care do not occur due to a lack of knowledge. They occur due to:

1. Missed or weak early cues

2. Cognitive overload and bias

3. Delayed escalation

4. Communication breakdowns

5. Team coordination failures

ED Grand Rounds exists to make these invisible factors visible, discuss them safely, and convert experience into improvement.

Evidence-informed design

The structure of ED Grand Rounds is informed by established safety science and medical education literature. The forum, therefore, serves both educational and patient-safety objectives

1. Safety-II (Resilient healthcare): learn from frontline adaptations (Walk-in case)

2. Dual-process & cognitive bias: surface real-time reasoning (Doctor case)

3. Just Culture: system learning without blame (M&M)

4. CRM / Human factors: teamwork behaviours under pressure (Teamwork demo)

5. Debriefing science: structured reflection (AI, GAS, Plus–Delta)

6. Retrieval practice/Adult learning theory: MCQs improve retention (Review)

Session Structure:

Each session follows a fixed structure to ensure consistency, relevance, and depth

Each segment was explicitly mapped to established evidence frameworks

1. Walk-In Case (Lead: EMS/Nursing team) – 20 min

A real ED patient encounter from the previous week is presented exactly as it was experienced at arrival. 

Purpose: To understand frontline judgement and early risk recognition (Safety-II).

Focus:

1. Initial information and uncertainty

2. Subtle cues that prompted concern or reassurance

3. Adaptive actions taken to maintain safety

Tool: Advocacy–Inquiry prompts

2. Doctor Case Path – 20 min

The treating doctor explains their thinking process in real time.

Purpose: To surface clinical reasoning under pressure, not guideline recall. (Dual-process)

Focus:

1. Prioritisation and decision points

2. Uncertainty and competing considerations

3. Escalation reasoning and timing

4. The doctor may introduce a brief academic framing ONLY to clarify:

• Why this decision mattered (Pathophysiology that explains urgency)

• Why uncertainty existed (Overlap syndromes, atypical presentations)

• Why escalation threshold chosen (Risk-benefit trade-off)

Tool: AI

3. M&M (Senior) – 20 min

A structured, non-punitive review of a panel-selected case.

Purpose: To convert errors and near-misses into shared system learning => risk amplification + system learning (Just Culture)

Focus:

1. Timeline reconstruction

2. Where and how risk increased

3. Human factors, communication gaps, and system friction

Tool: AI + GAS

Please note the Core distinction between

1. Doctor’s Clinical Decision Path (Forward-looking)→ “How I thought and decided in real time, given uncertainty.”

2. M&M Session (Backwards-looking) → “How the system and team dynamics amplified or mitigated risk.”

1. • • • Time orientation: Forward-looking       | M&M -> Backwards-looking |

       • Unit of analysis: Thinking       | M&M -> System + team |

       • Tone : Exploratory       | M&M-> Analytical |

       • Ownership: “I”        | M&M -> “We / the system” |

       • Question: “Why did I choose this?”    | M&M -> “Why did this make sense here?” |

4. Clinical Gestalt – 15 min

In acute care and emergency medicine, clinical gestalt ("gut feeling" or "clinical impression") is the rapid, intuitive recognition of disease patterns based on prior experience.

Purpose: To strengthen pattern recognition and decision-making using retrieval practice (scripts + retrieval)

Format:

• 3–5 spotters per session

• Presented by IMT trainee

• Identify → interpret → next action

Tool: strict spotter format (no teaching)

5. Modified Megacode (Teamwork demo) – 25 min

A live, scenario-based demonstration. Clinical complexity is deliberately kept simple; the spotlight is on team behaviour, not medical brilliance.

Purpose: To train Crisis Resource Management (CRM) skills that directly impact patient safety (leadership/communication/escalation)

Focus:

1. Leadership and role clarity

2. Communication and closed-loop commands

3. Escalation timing

4. Task prioritisation under pressure

Tool: GAS + Plus–Delta + rubric

6. Review (Google Form) – 5 min

Each session is observed by a multidisciplinary panel to ensure learning quality and psychological safety.

Purpose: To support reflective learning and close the learning–action loop. 

MCQ retrieval + 1 reflective/QI item

Attendance = form submission

Tool: MCQ + One Delta

Panel Composition:

1. Senior Emergency Physician (Chairperson, ED Grand Rounds)

2. Nursing / EMS representative

3. MEM resident representative

4. IMT MRCP representative

Roles: A panel member is not an examiner,/not a lecturer or not a judge. A panel member is an observer, sense-maker, and learning facilitator. 

Primary responsibility:

1. Protect non-punitive culture & psychological safety

2. Enforce time-boxing and segment integrity

3. Capture one actionable improvement per session 

Pre-Session Responsibilities: Before the session, panel members should:

1. Review the session agenda

2. Understand the intended learning focus (thinking, teamwork, communication)

3. Commit to non-punitive language

Panel members must not pre-form opinions about individuals or outcomes. During the session, panel members observe four domains:

A. Clinical Thinking: Were decisions explained, not justified?

B. Communication: Was the language clear and closed-loop?

C. Teamwork & Human Factors: Leadership visibility, Task delegation, and Closed-loop communication

D. ED System & Discipline: Equipment/process friction

Rules for Speaking During the Session (use one of the following techniques; evidence-based)

• Pendleton principle: Start with positives, limit corrective points, and focus on learner reflection first.

1. Ask what went well

2. Reinforce positives

3. Ask what could improve

4. Add one constructive suggestion

(Note: It is primarily designed for one-to-one feedback)

• Advocacy–Inquiry (AI); This model is used mainly in simulation debriefing. Structure:

• Advocacy: State an observation (neutral fact)

• Inquiry: Ask for participants’ thinking

Example: I noticed escalation was delayed when BP dropped. I’m curious what the team was considering at that moment.” => Why it fits: Non-judgemental, Invites thinking, Works in groups, & Protects safety

• GAS model: Best for closing discussion

  • • • Gather: What happened?

      • Analyse: Why did it happen?

      • Summarise: What will we change?

• Plus–Delta: Perfect for multidisciplinary settings (MDT meeting)

  • • Plus: What helped?

    • Delta (= change): What would we change next time?

This avoids blame and keeps energy constructive.

Starting with Plus is neurocognitive; it reduces threat response. Because when people sense evaluation, the brain shifts to defensive mode (amygdala activation), starting with “what worked” lowers threat, and preserves participation. 

“What went wrong?” implies: Error/Blame. “Delta” implies: Adjustment/Improvement/Forward-looking change

Example 1:

❌ “Why didn’t you escalate earlier?”

✅ “What would we change to make escalation easier next time?”

Example 2: 

• “Let’s quickly capture two things that helped today (Plus)

• One thing we should change before next week (Delta).

Summary:

Please note that excess feedback reduces learning retention

• Pendleton: best for 1:1 feedback   => | Structured, reflective |

• Advocacy–Inquiry: best for deep exploration => | Exposes thinking |

• Plus–Delta: It decides change, best for group (multidisciplinary) improvement => | Fast, safe, forward-looking | 

• GAS: best for closing the loop

In the Grandrounds, for one segment → use one dominant model.

• Case presentation: Advocacy–Inquiry (AI) => Why this fits best? Because the Goal = expose thinking, not judge performance, and will get multiple perspectives

• Morbidity & Mortality (M&M) Reflection => Best model: Advocacy–Inquiry + GAS (combined). Why: Because M&M is the highest-risk segment for blame, & 'Needs depth and closure. How to run it:

AI → explore decisions, biases, system factors

GAS → structure the discussion flow

No “what went wrong” questions. Only “what increased risk” questions

• Teamwork Demonstration/Modified Megacode: Best model: GAS + Plus–Delta => Why: Because this discussion is Behaviour-focused, Group performance, and needs actionable outcomes

How:

• • • • GAS to structure debrief

      • Plus–Delta to extract change

Panel language: “One thing that helped the team was.. One thing we should change next time is…”

• Communication & Service Training: Best model: Plus–Delta (primary) + AI (selective). Rule to apply:

  • • • Use Plus–Delta openly

      • Use AI only if a risky behaviour appears

“Let’s capture what language worked, and what we should change next time.”

• End-of-Session Closure: Best model: Plus–Delta (mandatory) => Converts discussion into action

Chair must say: “Our one change before next week is…”

Deploy them deliberately

• AI → when thinking matters

• GAS → when structure is needed

• Plus–Delta → when change is the goal

• Pendleton → Individual reflection

ED Grand Rounds – Session Structure in detail

1. The Case That Walked In (20 min)

Presenter: EMS / Nurse

What: 

Standardise how EMS presents uncertainty

One real ED patient encounter from the previous week

Initial information available upon arrival

Areas of uncertainty or ambiguity

Subtle cues that prompted concern or reassurance

What made the team pause, watch, or escalate

How the team adapted to incomplete or conflicting information

Actions taken to maintain safety despite uncertainty

The evidence logic for this section => This is Resilient performance analysis. (Hollnagel model); learning from what usually goes right.

Why Safety-II => The ED reality is that if staff followed rules exactly, patients would die! ED safety comes from Team anticipation & Informal escalation.

Safety-II is interested in:

• Early uncertainty, not confirmed sickness

• Weak signals, not obvious red flags

• Adaptive actions, not delays or mistakes

• Why things went right, not why they went wrong

• Avoid the traditional ways of presentation like One sick patient from last week, then discuss First decision, first red flags, first delays. The Hidden problems with this style (safety-1 approach) are

“Sick patient” → outcome-labelled

“Red flags” → checklist thinking

“Delays” → implies failure framing

This subtly pushes people toward error hunting, not adaptive success.

Background for the evidence: Erik Hollnagel is a Danish safety scientist. He worked in aviation, healthcare, and nuclear power industries. He asked a very uncomfortable question: “If healthcare workers make so many ‘errors’, why does the system succeed most of the time? That question changed modern safety science.

• Safety-I: the traditional way (how hospitals usually think). The core idea is Safety = absence of harm

Find “what went wrong” -> Identify error -> Fix the error -> Add a rule / protocol

Language used “Root cause” (RCA)

• Safety-II: Hollnagel’s correction (this is the upgrade). The Core idea is that safety = the ability to succeed under varying conditions. Not “no errors” — but resilience.

How it works => Study how work is actually done -> Understand adaptations -> Learn how people detect risk early -> Learn how they compensate for system gaps

Language used: “Adaptation”/“Anticipation”/“Resilience”

The Key insight is that people are not the problem. People are the solution.

Safety-I reduces failure ( for surgical procedures) = traditional patient safety

Safety -II ↑ses success (learn from what's going on) = future patient safety

In Walk-in Case Presentation, if the discussion is “What was the diagnosis?”, “What protocol should have been followed?” or “What went wrong?” => That is Safety-I thinking. However, Your EMS walk-in presentation should ask: Safety-II questions

• What made this patient feel at risk?

• What cues were weak but concerning?

• What uncertainty existed?

• What adaptation was made?

• What prevented deterioration?

This turns the walk-in case into a scientific safety exercise.

Sample: Side-by-side comparison, Walk-in Case: Safety-I vs Safety-II

Safety-I version ❌

• “Vitals were normal”

• “Diagnosis was unclear”

• “Later, the patient deteriorated”

Learning point: missed diagnosis

Safety-II version ✅

• “Vitals were borderline but trending”

• “EMS felt something was off”

• “We kept the patient in observation”

• “Early escalation prevented collapse”

Learning: early risk sensing worked

We are adopting this style because it changes behaviour 

After a few weeks:

• EMS stop apologising for “not knowing”

• Doctors stop dismissing early unease

• Teams learn to respect anticipation over certainty

That’s resilient healthcare in action. The walk-in case presentation was redesigned using Safety-II principles to examine frontline adaptive behaviours and early risk recognition under conditions of uncertainty, rather than retrospective error analysis. The presentation is not just ED education, but designing at a safety-science level. If we keep words like delay and red flags, people will hunt errors instead of studying resilience. Change the language → you change the thinking.

2. Clinical Decision Path (20 min)

Presenter: Emergency Doctor

What it really trains: 

Clinical reasoning under uncertainty

Explain thinking, not guidelines.

Decision-making, not diagnosis

Escalation judgement

Explicitly map: Cue → interpretation → action → consequence

Train presenters to verbalise 'why escalation felt hard'

Along with a brief topic discussion

Evidence base: 

1. Dual Process Theory (System 1 vs System 2), 

2. Cognitive bias literature (anchoring, premature closure), 

3. Acute care decision-making studies

Doctor-led case presentations were designed to surface real-time clinical reasoning using dual-process theory, with explicit exploration of intuitive judgment, analytical reasoning, and common cognitive biases known to affect acute care decision-making.

Dual Process Theory explains how doctors think

Cognitive bias literature explains why thinking fails

Acute care studies explain why outcomes suffer

Clinical Decision Path design is a practical solution to all three. This session trains

• Awareness of thinking mode

• Willingness to say “I was uncertain”

• Early escalation behaviour

• Safer decision-making under pressure

Background to the evidence: 

The Dual Process Theory (System 1 vs System 2), the core idea is that human decision-making runs on two parallel systems: 

1. System 1 — Fast, intuitive, automatic, Pattern recognition (In ED terms: “Something is not good in the initial appearance”)

2. System 2 — Slow, analytical, differential diagnosis, Guideline checking (In ED terms: ABCDE review)

Why this matters in emergency care: In the ED, you start in System 1 (you must), and you confirm with System 2. The Errors occur when: System 2 is never activated (misses primary assessment)

Cognitive Bias Literature (Anchoring, Premature Closure)

Cognitive biases are predictable shortcuts of System 1. They are normal human cognition under pressure.Viz,

1. Anchoring bias: Locking onto the first piece of information (symptom) and failing to adjust. ED example:

• • • • • • • “Young patient = functional”

            • “Known COPD = infective exacerbation”

            • “Normal BP = stable”

            • "Breathind difficulty" = "Pulmonary edema"

            • "B lines on POCUS" = "Pulmonary edema"

            • "Chest pain" = "ACS"

Why does it happen?

• Early labels simplify chaos

• High workload rewards speed over accuracy

2. Premature closure: Stopping diagnostic thinking once an explanation seems “good enough”. ED example:

• Stopping after one diagnosis

• Ignoring new conflicting data

• Delayed escalation

Biases increase with:

• Time pressure

• Fatigue

• Cognitive overload

• Hierarchy

Why this matters to  Grand Rounds 

• Makes biases discussable without blame

• Reframes them as system risks, not personal flaws

• Normalises saying: “At that point, I was anchored.” => That is advanced professional maturity.

Acute Care Decision-Making Studies 

Most acute care errors are not knowledge errors. They are:

1. Decision-timing errors

2. Escalation delays

3. Communication failures

4. Bias-driven misjudgements

Key findings from acute care research: Clinicians often recognise deterioration before they can articulate it. Delays occur when:

Uncertainty is uncomfortable

Escalation feels socially risky

Evidence feels “not enough yet”

In other words,  People sense danger early but hesitate to act.

The Clinical Decision Path addresses this through

4. • Forces articulation of early unease (System 1)

   • Validates uncertainty (Safety-II)

   • Examines escalation as a decision, not a failure

   • Uses AI and Plus–Delta to keep it non-punitive

It helps

• Awareness of thinking mode

• Willingness to say “I was uncertain”

• Early escalation behaviour

• Safer decision-making under pressure

3. M&M Reflection (20 min)

Presenter: Senior 

Purpose: To transform adverse events and near-misses into system learning, behavioural improvement, and risk reduction, without blame or personal judgement. => focuses on learning, not judgment.

Core principles followed: 

1. Just Culture principles

2. Modern M&M redesign literature

3. Human Factors Engineering

4. Crisis Resource Management (CRM)

Case Selection Criteria

• Involving uncertainty or escalation decisions

• Illustrating system or teamwork challenges

• Avoid: Rare diagnostic curiosities

Structure; 

1. Timeline Reconstruction (WHAT happened); Arrival → key decisions → outcome

Take a real ED case (with issued cues, delayed escalation, or system friction) from the previous week

2. Advocacy–Inquiry Exploration (WHY it made sense); Facilitator language: “I noticed X happened at this point. I’m curious what the team was thinking then.” Focus areas: Information documented in the EMR, Cognitive load and uncertainty, Environmental pressures, & Competing priorities

3. Human Factors & CRM Lens (HOW risk increased). Explicitly examine: 

Communication flow, 

Leadership clarity

Role allocation

Situational awareness

Escalation barriers

(Avoid diagnostic correctness debates. Examine coordination and timing)

4. GAS Closure (WHAT we change)

Gather: Key observations

Analyse: Why risk increased

Summarise: One behaviour or system change (one actionable takeaway)

Evidence: 

1. Just Culture

2. Modern M&M redesign literature

3. Human Factors & 

4. CRM

Language Rules

Allowed:

“This increased risk because…”

“Given the context, this decision made sense…”

Not allowed:

“Mistake”

“Error”

“Should have”

Naming individuals

Background for evidence: 

Just Culture — the foundation of modern M&M

Just Culture is a safety framework that separates:

• Human error (unintentional slips)

• At-risk behaviour (taking shortcuts under pressure)

• Reckless behaviour (conscious disregard of risk)

The core principle: We don’t ask “Who failed?” We ask “Why did it make sense for this action to occur at that time?”

The traditional M&M focuses on "errors" & Publicly dissects individual decisions => results Defensive behaviour, Silence from juniors and nurses, & Learning shuts down => This is anti-safety, even if intentions are good. What Just Culture demands in M&M

• Behaviour is discussed, not character

• Decisions are examined in context

• System pressures are explicit

• Blame language is prohibited

(This is why  AI + GAS choice is correct for the Panel as well)

Modern M&M redesign literature

Over the last 15–20 years, M&M sessions were found to be:

• Educationally inconsistent

• Psychologically unsafe

• Poor at generating system change

What modern literature recommends

• Be structured

• Focus on process, not outcome

• Include human factors

• Generate actionable system change

• Protect psychological safety

Key shift in language (old M&M -> Modern M&M)

  “Error” -> “Risk amplification”

“What went wrong?” -> “What increased risk?”

“Missed diagnosis” -> “Decision made under uncertainty

“Delay” -> “Timing influenced by context”

Human Factors & CRM (Crisis Resource Management): We borrowed it from the aviation industry

Why M&M must include them, because most crises fail due to coordination, not knowledge. human factors study how

• Humans interact with systems/protocols

• Cognitive limits affect performance

• Environment, workload, and design influence decisions

CRM focuses on non-technical skills:

1. Leadership

2. Communication

3. Situational awareness

4. Task management

5. Escalation

Why classic M&M ignored this in Traditional M&M: Over-focused on diagnosis, Ignored teamwork, Ignored communication, Ignored hierarchy effects (basically focuses on major causes of harm, instead of safety II)

How Human Factors & CRM reshape M&M -> instead of asking: “Was the diagnosis correct?”, ask:

• “How did information flow?”

• “Who had situational awareness?”

• “When did escalation feel difficult?”

• “What distractions or overload existed?”

Mapping the evidence-based approaches to M&M

Evidence base -> What it targets (How M&M applies it)

• • • Just Culture -> Blame reduction (No naming, no judgement)

    • Modern M&M ->  Learning quality (Structured timeline + AI)

    • Human Factors -> Cognitive limits (Bias, overload, interruptions)

    • CRM -> Team failure points (Leadership, communications, escalation)

The M&M session is designed using Just Culture principles and modern morbidity and mortality frameworks, incorporating human factors and crisis resource management concepts to focus on system vulnerabilities, decision-making under uncertainty, and team behaviours rather than individual blame.

• Just Culture answers “How do we discuss failure safely?”

• The modern M&M redesign answers, “How do we make M&M useful?”

• Human Factors & CRM answer “Why competent teams still fail.”

Courtesy: This framework is grounded in the work of James Reason and modern safety science. The response mapping is done with below ideas

• Human Error-> Console, redesign system

• At-Risk Behaviour-> Coach, remove incentives

• Reckless Behaviour->Disciplinary (outside M&M) => The Art of War principle

Difference between M&M and RCA concepts

Root Cause Analysis (RCA) is a formal investigative tool used after a serious adverse event. The primary question is “Why did this failure happen?"  to identify system-level causes, and prevent recurrence of the same error. It uses the problem dissection tool; 5 "why" (keep asking “Why?” until you hit a cause that is actionable and systemic, not human blame). Example;

1. Why did antibiotics get delayed? → Order placed late

2. Why was the order late? → Sepsis not recognised

3. Why not recognised? → Vitals not flagged

4. Why not flagged? → No sepsis trigger in triage

5. Why? → Protocol gap

M&M is a regular clinical learning forum using real cases. The primary question is  “What can we learn from this case?”

Core purpose: 

• Improve clinical reasoning

• Improve decision-making

• Share cognitive lessons

• Build professional maturity

Side-by-side comparison (RCA & M&M)

• Purpose   | Prevent recurrence.   | M&M=> Improve learning  |

• Trigger   | Serious harm. | M&M => Any meaningful case |

• Focus     |System failure | M&M => Clinical reasoning & decisions |

• Style     | Formal investigation          | M&M => Educational discussion  |

• Ownership | Institution leadership     | M&M => Clinical teams   |

• Outcome   | Action plan | M&M => Insight & learning   |

• Culture   | Safety enforcement | M&M => Professional growth  |

RCA asks: “What broke in the system?”

M&M asks: “What should we think or do better next time?”

RCA without M&M → bureaucratic 

M&M without RCA → repeated mistakes

High-functioning ED/ICU needs BOTH

4. Clinical Gestalt segment (15 min)

Presenter: IMT Resident (ED Grand Rounds provides structured exposure to acute medical cases equivalent to the unselected acute take. Active participation in ED Grand Rounds demonstrates engagement with acute care learning, reflective practice, and patient safety-focused discussions.)

Purpose: 

1. Train rapid pattern recognition

2. Risk stratification

3. “Next best action” thinking

Format rule:

• 2-3 spotters per session

• 60–90 seconds per spotter

• No long explanations

• Focus on “What is it?” → “Why does it matter?” → “What would you do next?”

Evidences used:

Script Theory in Expert Clinicians

Background Evidences:

Script theory comes from cognitive psychology (Henk Schmidt's work). It explains how experts recognise situations quickly without conscious step-by-step reasoning. 

Cognitive psychology deals with how the mind actually processes information, from input to action- Not feelings, not personality => It’s about thinking mechanics. The two engines of thinking are system 1 (fast, intuitive) and system II (logical, analytical). 

The core idea (script theory) is that, with experience, clinicians build illness scripts, includes typical presentation patterns, red flags, and Immediate actions. So when an expert sees a patient, they don’t start from first principles. They subconsciously ask: “Which script does this resemble?”

Expert vs novice thinking

Novice

• Uses analytic reasoning

• Builds long differentials

• Slow, effortful

Expert

• Matches patterns

• Filters irrelevant data

• Recognises danger early

• Faster, safer in acute care

• This is not laziness — it is cognitive efficiency.

Relevance: Since ED work is time-critical, experts survive by: Rapid script activation, Early risk recognition, & Quick “next step” decisions. Spotter session train scripts! Spotters ask (Pattern > detail):

• “What is this?”

• “Why is it dangerous?”

• “What do you do next?”

This mirrors script activation, not textbook recall.

Note: Script dont come from one exposure. They form from multiple encounters.

The spotter segment was designed using script theory, providing short exposure to high-risk patterns to strengthen rapid recognition and next-action decision-making in acute care.

5. Teamwork Megacode (25 min)

Managing the sick patient as a live scenario

Focus on:

• Role clarity

• Communication

• Leadership under pressure

• Task delegation

• Escalation timing

Purpose: To strengthen non-technical skills that directly impact patient safety.

Not a perfect algorithm execution. The spotlight is on team behaviour, not medical brilliance. Because Most ED failures happen here, not in diagnosis, but in coordination.

Evidence base

Crisis Resource Management (CRM)

Simulation debriefing literature

Aviation safety models

Evidence Background:

Crisis Resource Management (CRM): It originated in aviation and was adapted to healthcare for managing high-stakes, time-critical situations with multiple team members - Exactly for ED.

CRM is not about medical knowledge. It is about how teams function when things go wrong.

Core CRM domains (focuses on non-technical skills):

1. Leadership & followership

2. Communication (clear, closed-loop)

3. Situational awareness

4. Task prioritisation

5. Resource utilisation

6. Escalation and call-outs

Remember, Most crises fail due to coordination failure, not knowledge failure. CRM provides a shared behavioural framework so teams don’t rely on individual brilliance.

Simulation Debriefing Literature: It explains why the “after” matters more than the “scenario”

Simulation research consistently shows that most learning does NOT occur during the scenario. It occurs during the debrief.

A poorly debriefed simulation = wasted time.

The debriefing (High-quality debriefing ) literature emphasises

• Be structured

• Be psychologically safe

• Explore thinking, not performance

• Focus on behaviours and decisions

• End with actionable change

This is where Advocacy–Inquiry, GAS, and Plus–Delta come in.

“Debriefing with Good Judgment” matters, rejects:

• Shaming

• Teaching-by-lecture

• “What went wrong?” interrogation

Instead, asks: “Given what you knew at the time, why did that action make sense?”

The modified megacode (The teamwork megacode)

• Keeps clinical content simple

• Shifts focus to team behaviour

• Uses structured debriefing

• Extracts one actionable change

Aviation Safety Models (Where all of this comes from)

The aviation industry realised something disturbing in the 1970s: Pilots were highly skilled, Aircraft were technically sound, yet crashes still occurred. Investigation showed: The aircraft didn’t fail. The team did. The Swiss Cheese Model shows (This model directly influenced healthcare safety thinking)

• Accidents occur when multiple small failures align

• Human actions are one layer, not the root cause

• Systems must be designed to absorb human variability

Aviation responded by: "Crew Resource Management" (Healthcare borrowed this as "Crisis Resource Management, the CRM") => 

• Flattening hierarchy

• Standardising communication

• Training captains to invite challenge

• Training juniors to speak up

Outcome => Dramatic reduction in fatal accidents

Concepts:

• Aviation safety explains "Why accidents happen?"  => Systems, not individuals 

• CRM explains "How teams should behave?" => train the team with Modified megacode

• Simulation debriefing explains "How teams learn" =>   GAS + AI + Plus–Delta

The teamwork demonstration and debriefing components were informed by Crisis Resource Management principles, simulation debriefing literature, and aviation safety models. These frameworks emphasise non-technical skills, structured reflection, and system-focused learning as key determinants of safety in high-risk, ED environments.

Note: CRM training fails if participants are cognitively overloaded by medical detail.

Why focus on communication and escalation? Because aviation learned long ago: Silence kills more reliably than ignorance.

1. Aviation taught us why teams fail

2. CRM taught us how teams should act

3. Simulation debriefing taught us how teams learn

The ED Grand Rounds has operationalised all three.

If we don’t measure teamwork explicitly (during training as well as in the resuscitation bay), people will keep believing: “The problem was medical complexity.” This rubric makes it visible that: How we work together is often the real determinant.

6. Review session

Format: Reflective submission (Google Form)

Attendance = submission

Evidence base:

Reflective learning theory

Adult learning theory (Knowles)

QI (quality improvement) learning loops

Reflective Learning Theory: It says that experience alone does not lead to learning. Learning happens when experience is examined, interpreted, and reframed. Two types of reflection

1. Reflection-in-action: Thinking while doing (e.g., adjusting during resus)

2. Reflection-on-action: Thinking after the event (e.g., Grand Rounds reflection)

ED Grand Rounds primarily trains reflection-on-action, which then improves reflection-in-action during real shifts. The MCQs test knowledge recall, not behaviour.

Adult Learning Theory (Malcolm Knowles): Adults learn best when the content is relevant and when they want to know why something matters. The ED Grand Rounds fits adult learning perfectly - uses real cases (relevance), solves real problems (problem-centred), and invites experience sharing (peer learning), allowing autonomy (reflection, not instruction)

QI Learning Loops: Learning without action does not improve systems. So the review continues even after Grandrounds. The QI frameworks emphasise closed learning loops:

1. Identify an issue

2. Reflect and analyse

3. Implement a change

4. Review impact

Most educational sessions:

• End with “good discussion”

• Do not assign ownership

• Do not revisit outcomes

This may creates learning fatigue. 

The review MCQs are evidence-based for: Knowledge consolidation, pattern reinforcement, and retrieval practice. They’re just insufficient if used alone. Hence, added a reflective/QI element to this session.

MCQ = Retrieval, not Reflection

Reflection → action

Education → governance

1. Reflective learning answers "How experience becomes insight" 

2. Adult learning style questions explain "How professionals learn best" through Case-based questions

3. QI loops  oversee "How learning changes systems" through emphasising One Delta + follow-up

The final review component was informed by reflective learning theory and adult learning principles, incorporating a quality improvement learning loop to ensure that reflection translated into actionable system and behavioural change.”

The review MCQs are framed as

• Knowledge Anchoring  

• Retrieval Check

• Not as  Assessment/Judgement/Primary learning outcome

• Attendance linked to submission; Attendance tracking is a logistical function

MCQ Pattern

• MCQs should be (retrieval practice): Case-linked, “Next step” oriented. Not trivia

• 5–7 MCQs, using Google Form

• One Reflective / QI Item will be there. 

Example: a question on one teamwork or communication behaviour practice

Each ED Grand rounds session concluded with a short online review consisting of case-linked MCQs to promote retrieval practice, combined with a single reflective or quality-improvement prompt to support reflective learning and close the learning loop.

Rules of engagement

1. No blaming, no naming

2. Focus on process, not outcomes

3. Speak from “what I saw / what I thought”

4. One person speaks at a time

5. Respect multidisciplinary voices

ED Grand Rounds Coordination Team

ED Grand Rounds is coordinated by a dedicated internal team to ensure consistency, discipline, and continuity.

Coordinators’ responsibilities:

1. Case selection and presenter prep

2. Zoom + logistics

3. Form collection + dashboard updates

4. Follow-up on action items

Review Team: ED Grand Rounds is not a collection of activities. It is a designed safety intervention.

Your role is to protect the link between evidence → structure → behaviour.

• Dr Jean K Babu, ED Grandrounds Secretary

• Dr Mukthar - Panel chair

• Dr Shanif Muhammed, ED Faculty

• Dr Nimshya, Debriefer

• Dr Fathima, ED ICU Coordinator

• EMS Tenzin, EMS coordinator

• EMS Harsha, ED In-Charge

• Dr Aswathi, IMT Chief Resident

• Dr Adeeba, MEM Chief Resident

How the review team measures impact

Discuss → Debrief → One Delta → Assign owner → Review next week

1. Attendance & participation

2. Teamwork and CRM behaviours (panel rubric)

3. Psychological safety sentinel flags

4. Top recurring risks (monthly synthesis)

5. Actions completed vs pending

Post–ED Grand Rounds Debrief; ED HOD + Coordination Team Review

The debrief is based on panel Google Form submissions, not opinions.

Purpose: A closed debrief within 24–48 hours after ED Grand Rounds (20–30 minutes) is conducted by the HOD with the coordination team to review learning quality, psychological safety, and action feasibility, ensuring that insights translate into sustained system improvement. The HOD’s role is stewardship of the system, not adjudication of people. Also, ensure ED Grand Rounds becomes a high-reliability process

1. Session Integrity Check: Did ED Grand Rounds function as designed? 

2. Psychological Safety Scan: Was it safe to speak openly?

3. Learning Quality Review: Was the learning meaningful, not cosmetic?

4. Action Item Validation: Are the identified actions realistic and owned?

5. Pattern Recognition (Monthly Lens)

   • • Are the same risks recurring?

     • Is the same segment repeatedly weak?

     • Is escalation still being delayed?

     • Is teamwork improving or stagnating?

6. The Grand Rounds system itself continues to improve

Why ED Grand Rounds Is Designed This Way

It connects Patient-Safety & Decision-Making Evidence to Practice.

What do we mean by “evidence from patient safety”? => Classic safety thinking (“Safety-I”) focused on adverse events: identify what went wrong. Modern safety science (“Safety-II / Resilient Healthcare”) adds a second lens: how things usually go right under variable conditions (“work-as-done”). “Evidence from patient safety” means research + real-world safety programs showing outcomes in acute care. It studies how and why harm occurs in real clinical environments. Over the last two decades, this research has shown that:

• Most adverse events occur before the diagnosis is clear

• Harm often results from delayed escalation, not a wrong diagnosis

• Communication and teamwork failures are major contributors

• Systems shape behaviour more than individual competence

Safety depends less on what clinicians know and more on how clinicians think, interact, and adapt under pressure.

What do we mean by “decision-making research”? => Decision-making research examines how clinicians actually make decisions, especially in time-critical settings like the ED. Key findings include:

• Clinicians rely heavily on fast, intuitive thinking (pattern recognition)

• This is necessary, but vulnerable to cognitive biases (anchoring, premature closure)

• Safer decisions occur when clinicians reassess, seek disconfirming cues, and escalate early

• Expertise is built through repeated exposure to decision moments, not lectures

How this evidence shaped ED Grand Rounds

1. Safety science: Classic safety thinking (“Safety-I”) focused on adverse events: identify what went wrong and fix. Modern safety science, known as “Safety-II / Resilient Healthcare,” introduces a second lens to understanding how things usually go right under variable conditions. work-as-imagined vs work-as-done. This is the logic behin walk-in session; forces discussion at the moment of uncertainty, before hindsight and labels.

2. Just Culture framework separates behaviours into categories, each requiring a different response:

1. Human error (slips, lapses) → console + redesign systems

2. At-risk behaviour (drift, shortcut, risk not recognised) → coach + remove pressures

3. Reckless behaviour (conscious disregard of substantial risk) → manage separately

Human factors: harm often comes from predictable conditions (patient safety research); 

• cognitive load (too much to process)

• interruptions and multitasking

• crowding/time pressure

• fatigue

• poor interfaces between teams/services

Just Culture is a safety tool to keep discussions truthful and useful

Modern safety practice asks, “Why did this make sense at the time?” (instead of “Who failed?”).

This is the logic behind M&M, not a clinical lecture.

3. Safety evidence from cognitive science shows

1. Cognitive failures include:

• Anchoring (sticking to first impression)

• Premature closure (stopping once a plausible diagnosis appears)

2. Dual-process theory explains this:

• System 1 = fast, intuitive

• System 2 = slow, analytical

Doctor Clinical Decision Path: It trains clinicians to reveal their thinking, identify inflection points, and practice safe “switching” and escalation.

4. A huge chunk of safety failures in acute care are not knowledge failures—they’re:

• unclear leadership

• role confusion

• closed-loop communication failure

• poor situational awareness

• delayed escalation

CRM is the set of behaviours designed to prevent exactly that. This is why “Teamwork Demo” exists

Walk-in case: Safety-II + work-as-done: learn early uncertainty & frontline adaptations.

Doctor decision path: Dual-process + cognitive bias: reveal thinking traps & escalation reasoning.

Clinical Gestalt: Reinforces pattern recognition and next-step action (high-frequency, short cycles). (This is consistent with expertise-building logic even when not cited formally.)

M&M: Just Culture + human factors: system learning without blame.

Teamwork demo: CRM behaviors + structured debriefing: safety through team performance.

Review: MCQ + reflection anchors learning and produces QI actions (retrieval + learning loop).

ED Grand Rounds Success

• Uncertainty is openly discussed

• Early escalation is valued

• EMS and junior doctors' voices are heard

• One actionable learning emerges every session

• The same risks become less frequent over time

In Summary

ED Grand Rounds is not a lecture series. 

In the ED, Everyone starts with 

• incomplete information

• Patients evolve

• Early impressions are often provisional

If people feel they must defend their first decision, they:

• Delay escalation

• Ignore weak signals

• Rationalise instead of reassessing

That’s how harm happens

ED Grand rounds is a culture-building and safety-improvement platform designed to help emergency teams think clearly, communicate effectively, and work together under pressure.

Consistency built the system.

Reflection strengthens it.

Teamwork sustains it.

Standard Presenter slide heading

The strategic rationale for adopting a standardised presentation format is

• If we don’t standardise slides, panels can’t score reliably

• If we don’t map forms to evidence, reviewers won’t buy it

Hence, if we do both, this becomes:

• Auditable

• Replicable, &

• Publishable