Like many of you, I watched over 40,000 people run the London Marathon last weekend.  It was fascinating to see the mix of backgrounds and abilities all attempting the 26.2 mile run and all with their own personal reasons.  This reminded me of the marathon in Boston a few years back where shocking events were to unfold and After Action Review (AAR) was to come into its own once again.

There were several AARs held after the marathon bombing on April 15th 2013, and each of them provided profound insights into how the Boston healthcare system responded on this terrible day.   Three people died and 247 were injured, many with considerable limb damage, yet incredibly, no one who arrived at a trauma centre alive subsequently died.

The first bomb went off at 2.50pm and casualties arrived at the first trauma centre at 3.09pm. Because the nursing shift changes at 3pm, there were sufficient staff available to put the Emergency Medical System Mass Casualty Incident (MCI) plan into action and clear emergency departments of other patients.

The Boston marathon takes place on the local holiday called Patriots’ Day, when hospitals have less surgery scheduled so time to the operating room was impressively rapid and undoubtedly saved lives.  So ‘luck’ clearly played a part in saving lives and – whilst there may be no practical lessons to be learnt from this – perhaps there are some philosophical and moral ones which can be just as valuable in these circumstances.


After Action Review lessons

The practical lessons learnt from the After Action Review which have led to the updating of the MCI Plan include:

  • Creating a ‘pooling room’ for spare staff to be drawn on as required.  One of the trauma centres did this and it was an effective way to use the many staff arriving to volunteer along with that extra shift of staff.
  • A review of the triage processes for MCI events of this type was also done, as less than 50% of casualties arrived with mass-casualty triage tags. These tags help decide the level of urgency for medical attention and treatment. Uncertainty about additional explosives created a sense of urgency in loading people into ambulances, so tags were not attached to the most seriously injured. However sufficient manpower in the hospitals did allow for effective triage once casualties arrived and the lesson is that field triage may not always be a realistic expectation and instead a universal and robust hospital-level triage protocol should be developed.
  • One of the simpler lessons learnt was about tourniquets. The importance of these for saving lives that day in Boston has meant that it has now been recommended to be included in the national first aid curriculum.

Applying these lessons to your workplace

Something as simple as tourniquet training for first aiders is the type of lesson which we can all understand as a constructive outcome from an After Action Review. Without the structured space of an AAR to think together, would this level of clarity emerge about what is important to save future lives?  My experience suggests it’s not worth taking the risk.

I would like to applaud all those who called for, facilitated and participated in the After Action Review process as, not only did it generate incredibly valuable learning for future mass casualty incidents, it also provided a safe and supportive space during which people could reflect and try to make sense together of the significant human effort to do their very best on a difficult day.

Not just for exceptional events

Yet we shouldn’t only use After Action Review for exceptional events such as this.  The appetite to learn may not be as compelling in our more everyday workplaces but the value can be just as great. Unique emergencies provide lessons about behaviour under exceptional circumstances, yet more routine events create multiple opportunities to learn how to do it better every single day.


What do you do to achieve clarity with your colleagues about what is important? How good are you at capitalising on the benefits of shared learning and avoiding any blame?  Would you like to hear more about creating this habit in your organisation?  Visit the AAR section of our website or please drop me a line so we can arrange a chat.

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