This scenario presents a professionally challenging situation due to the inherent unpredictability of neurosurgical procedures and the critical need for immediate, effective action to ensure patient safety. The surgeon is faced with an unexpected intraoperative complication that directly threatens the patient’s neurological function and potentially their life. The challenge lies in rapidly assessing the situation, formulating a plan, and executing it decisively while managing the stress and pressure of the operating room environment. This requires not only technical skill but also robust crisis resource management principles. The best approach involves immediate, clear communication and a structured problem-solving process. This includes pausing the primary surgical task to fully assess the nature and extent of the complication, consulting with available team members for their input and expertise, and collaboratively developing a revised surgical plan. This systematic approach aligns with established principles of patient safety and professional conduct, emphasizing teamwork, clear communication, and evidence-based decision-making. Such a process is implicitly supported by ethical guidelines that mandate acting in the patient’s best interest and by professional standards that encourage collaboration and continuous learning. An incorrect approach would be to proceed with the original surgical plan without adequately addressing the complication. This demonstrates a failure to prioritize patient safety and a disregard for the immediate threat posed by the unexpected event. Ethically, this breaches the duty of care and could be considered negligence. It also fails to utilize the collective knowledge of the surgical team, which is a cornerstone of effective crisis management. Another incorrect approach would be to make a unilateral decision to alter the surgical plan without consulting the team or pausing to fully assess the situation. This bypasses valuable input from other experienced professionals, potentially leading to suboptimal or even harmful decisions. It undermines the collaborative nature of surgical care and can create communication breakdowns within the team, increasing the risk of error. Finally, an incorrect approach would be to become overly focused on the technical aspects of the complication without considering the broader implications for the patient’s overall neurological outcome or the potential need for alternative strategies. This narrow focus can lead to missed opportunities for more effective interventions and a failure to adapt to the evolving intraoperative circumstances. Professionals should employ a structured decision-making framework that includes: recognizing the deviation from the expected course, pausing to assess the situation thoroughly, gathering information from all available sources (including team members), generating potential solutions, evaluating the risks and benefits of each solution, selecting the best course of action, and executing it with clear communication and ongoing reassessment. This framework, often referred to as a “stop, think, act” or “assess, plan, execute” model, is crucial for managing unexpected events in high-stakes environments.

Scenario Analysis: This scenario presents a challenge in navigating the intersection of professional development, institutional policy, and the specific requirements of a high-stakes fellowship exit examination. The critical aspect is ensuring that the candidate’s preparation and eligibility are assessed objectively and in alignment with the examination’s stated purpose, while also considering the practicalities of their current clinical role. Misinterpreting eligibility criteria or applying them inconsistently could lead to unfair assessment, potential legal challenges, and damage to the reputation of both the candidate and the examination board. Correct Approach Analysis: The best professional approach involves a thorough review of the official documentation outlining the purpose and eligibility criteria for the Critical North American Functional Neurosurgery Fellowship Exit Examination. This documentation, established by the governing body, will precisely define the academic, clinical, and experiential prerequisites for examination candidacy. Adhering strictly to these established guidelines ensures fairness, transparency, and the integrity of the examination process. The purpose of the examination is to certify a minimum standard of competence in functional neurosurgery, and eligibility criteria are designed to ensure candidates have achieved the necessary foundational knowledge and skills. Therefore, verifying that the candidate meets all documented requirements, without deviation or subjective interpretation, is paramount. Incorrect Approaches Analysis: One incorrect approach is to rely on informal discussions or anecdotal evidence regarding eligibility. This bypasses the official regulatory framework and can lead to misinterpretations or the acceptance of unqualified candidates, undermining the examination’s purpose of ensuring a high standard of practice. Another incorrect approach is to prioritize the candidate’s current clinical workload or perceived immediate need for certification over the established eligibility criteria. While a candidate’s clinical contributions are valuable, they do not supersede the formal requirements designed to guarantee competence. This approach risks allowing individuals to sit for the examination before they have adequately prepared, potentially compromising patient safety and the credibility of the certification. A further incorrect approach is to allow institutional convenience or administrative expediency to dictate eligibility. For instance, fast-tracking a candidate due to departmental pressure or a perceived administrative shortcut, without rigorous adherence to the examination’s stated purpose and eligibility, violates the principles of fair and objective assessment. Professional Reasoning: Professionals faced with such a situation should adopt a systematic decision-making process. First, they must identify and consult the definitive source of information: the official examination guidelines and regulatory framework. Second, they should objectively assess the candidate’s qualifications against each specific criterion outlined in these documents. Third, any ambiguities or potential conflicts should be clarified through the appropriate channels, typically the examination board or its designated administrative body, rather than through informal means. Finally, decisions regarding eligibility must be made and communicated in a transparent and consistent manner, ensuring that all candidates are treated equitably and that the integrity of the examination process is maintained.

The assessment process reveals a scenario that is professionally challenging due to the inherent risks associated with neurosurgical procedures, particularly the use of energy devices. The surgeon must balance the need for effective hemostasis and tissue dissection with the paramount duty to avoid unintended thermal injury to critical neural structures. Careful judgment is required to select the appropriate energy device and parameters, considering the specific tissue type, anatomical location, and proximity to vital structures. The best professional practice involves a systematic, evidence-based approach to energy device selection and safety. This includes a thorough pre-operative assessment of the surgical field, a clear understanding of the capabilities and limitations of each available energy device, and the implementation of established safety protocols. Specifically, this entails utilizing the lowest effective energy setting, employing intermittent application, maintaining adequate distance from neural tissue, and employing visual confirmation of tissue effect. This approach aligns with the ethical principles of beneficence and non-maleficence, ensuring that the patient’s well-being is prioritized by minimizing the risk of iatrogenic injury. Furthermore, adherence to institutional guidelines and best practice recommendations from professional neurosurgical societies reinforces this commitment to patient safety. An incorrect approach would be to rely solely on surgeon experience without a systematic risk assessment, potentially leading to the use of excessive energy or inappropriate device selection. This fails to uphold the ethical obligation to employ all reasonable precautions to prevent harm. Another incorrect approach is to prioritize speed of dissection over meticulous technique, which can result in thermal spread and unintended damage to adjacent neural tissues, violating the principle of non-maleficence. Finally, neglecting to confirm the desired tissue effect visually before sustained energy application, or failing to maintain adequate insulation and grounding of the device, represents a direct breach of safety protocols and an unacceptable risk of patient harm, contravening established standards of care and potentially violating regulatory requirements for medical device safety. Professionals should employ a decision-making framework that begins with a comprehensive pre-operative risk assessment, considering the specific anatomical challenges and potential complications. This should be followed by a deliberate selection of instrumentation and energy devices based on evidence-based guidelines and institutional protocols. During the procedure, continuous vigilance, clear communication with the surgical team, and adherence to established safety checklists are crucial. The decision to use or adjust energy device settings should always be guided by the principle of achieving the surgical goal with the least possible collateral damage.

This scenario presents a significant professional challenge due to the rapid deterioration of a patient with severe traumatic brain injury (TBI) in a critical care setting. The urgency of the situation, coupled with the potential for irreversible neurological damage, demands immediate and precise intervention. The physician must balance aggressive resuscitation efforts with the need to avoid iatrogenic complications, all while adhering to established protocols and ethical considerations for patient care. The best approach involves a systematic, evidence-based protocol for managing elevated intracranial pressure (ICP) and cerebral edema in the context of severe TBI. This typically begins with optimizing cerebral perfusion pressure (CPP) through fluid resuscitation and vasopressors if necessary, ensuring adequate oxygenation and ventilation, and controlling fever. If these initial measures are insufficient, osmotic therapy (e.g., hypertonic saline or mannitol) is indicated to reduce ICP by drawing fluid out of the brain parenchyma. Neuromuscular blockade and sedation are crucial for preventing agitation and hypermetabolism, which can exacerbate ICP. Surgical decompression, such as decompressive craniectomy, is reserved for refractory ICP elevations that fail to respond to medical management and is a critical intervention to prevent herniation. This multi-modal strategy is supported by neurocritical care guidelines and ethical principles emphasizing the preservation of life and neurological function. An approach that solely focuses on aggressive fluid resuscitation without considering the potential for exacerbating cerebral edema would be professionally unacceptable. Excessive crystalloid administration can worsen brain swelling, leading to increased ICP and poorer outcomes, violating the principle of “do no harm.” Similarly, initiating osmotic therapy without first optimizing CPP and ensuring adequate ventilation and oxygenation is premature and potentially harmful, as it may not address the underlying physiological derangements contributing to elevated ICP. Relying solely on surgical intervention without attempting less invasive medical management first is also inappropriate, as it bypasses established treatment algorithms and carries significant surgical risks. Professionals should employ a structured decision-making process that begins with a rapid assessment of the patient’s neurological status and hemodynamic stability. This should be followed by the implementation of a tiered management strategy, starting with basic life support and progressing to more advanced interventions as indicated by the patient’s response and ICP monitoring. Continuous reassessment and adaptation of the treatment plan based on the patient’s evolving condition are paramount. Ethical considerations, including informed consent (when possible) and the patient’s presumed wishes, should guide all decisions, particularly when considering aggressive or invasive treatments.

This scenario presents a professional challenge due to the inherent risks associated with neurosurgical interventions, particularly in the context of a fellowship exit examination where the candidate’s competence is being rigorously assessed. The pressure to demonstrate mastery while navigating complex patient factors requires a nuanced and ethically grounded approach to risk assessment. Careful judgment is paramount to ensure patient safety and uphold professional standards. The best approach involves a comprehensive, multi-disciplinary assessment that prioritizes patient safety and informed consent. This includes a thorough review of the patient’s medical history, imaging, neurological status, and any co-morbidities. Crucially, it necessitates open and honest communication with the patient and their family regarding the potential risks, benefits, and alternatives to the proposed surgical intervention. This collaborative approach aligns with ethical principles of beneficence, non-maleficence, and patient autonomy, as well as regulatory expectations for informed consent and patient-centered care. The fellowship program’s guidelines likely emphasize a structured risk stratification process that integrates clinical data with patient values and preferences. An approach that focuses solely on the technical feasibility of the surgery without adequately considering the patient’s overall health status or their understanding of the risks is professionally unacceptable. This would represent a failure to adhere to the principle of non-maleficence by potentially exposing the patient to undue harm. Furthermore, neglecting thorough patient and family communication about risks and alternatives constitutes a violation of the ethical and regulatory requirement for informed consent, undermining patient autonomy. Another professionally unacceptable approach is to proceed with the surgery based on the assumption that the fellowship candidate’s desire to perform the procedure outweighs potential patient risks, without a robust, independent assessment of those risks. This prioritizes the candidate’s learning objectives over the patient’s well-being, a clear ethical breach. It also fails to meet the standards of supervised practice and patient advocacy expected in a fellowship setting. Finally, an approach that delays or avoids a definitive risk assessment due to time constraints or a desire to avoid difficult conversations is also professionally flawed. This inaction can lead to suboptimal patient outcomes and represents a failure to uphold the duty of care. Regulatory frameworks and ethical guidelines consistently mandate proactive and thorough risk assessment as a cornerstone of safe medical practice. Professionals should employ a decision-making framework that begins with a comprehensive data gathering phase, followed by a structured risk-benefit analysis. This analysis must then be integrated with patient-specific factors, including their values and preferences, through open and transparent communication. The final decision should be a shared one, documented meticulously, and continuously re-evaluated as the patient’s condition evolves.

The assessment process reveals a common challenge for candidates preparing for high-stakes fellowship exit examinations: balancing comprehensive preparation with efficient resource utilization and a realistic timeline. This scenario is professionally challenging because a poorly structured preparation plan can lead to burnout, knowledge gaps, or an inability to recall critical information under pressure, ultimately impacting patient care if the candidate is not adequately prepared. Careful judgment is required to select a preparation strategy that is both thorough and sustainable. The best approach involves a structured, multi-modal preparation strategy that begins early and incorporates a variety of resources tailored to the specific demands of the Critical North American Functional Neurosurgery Fellowship Exit Examination. This includes systematically reviewing core neurosurgical principles, focusing on functional neurosurgery subspecialty literature, and engaging with practice questions and mock examinations that simulate the exam format and difficulty. Early identification of knowledge gaps through self-assessment and targeted study is crucial. This approach aligns with ethical obligations to maintain professional competence and ensure readiness for independent practice, as expected by regulatory bodies and professional organizations overseeing neurosurgical training and certification. It prioritizes a deep understanding of the material over rote memorization and allows for adaptation based on performance in practice assessments. An approach that relies solely on reviewing lecture notes from fellowship training without supplementing with current literature or practice questions is professionally unacceptable. This fails to address the dynamic nature of medical knowledge and the specific format of a high-stakes examination, potentially leading to a superficial understanding and an inability to apply knowledge in an exam context. It also neglects the ethical imperative to stay current with advancements in the field. Another unacceptable approach is to cram extensively in the final weeks before the examination, neglecting foundational knowledge and relying on memorization of isolated facts. This method is unlikely to foster deep understanding or the ability to integrate complex concepts, which is essential for functional neurosurgery. It also increases the risk of cognitive overload and poor performance due to stress and fatigue, failing to meet the professional standard of preparedness. Furthermore, an approach that exclusively focuses on practice questions without a solid understanding of underlying principles is also flawed. While practice questions are vital for assessment and familiarization, they are most effective when used to reinforce and test knowledge gained through comprehensive study. Relying solely on questions without a strong theoretical foundation can lead to misinterpretations and an inability to adapt to novel or complex scenarios presented in the examination. The professional decision-making process for similar situations should involve a self-assessment of learning style and existing knowledge base, followed by the development of a realistic, phased study plan. This plan should incorporate diverse learning modalities, regular self-testing, and feedback mechanisms. Prioritizing understanding over memorization, seeking mentorship from experienced colleagues, and maintaining well-being are critical components of effective preparation for any advanced medical examination.

This scenario presents a professionally challenging situation because it requires a neurosurgeon to balance immediate patient needs with the ethical and regulatory obligations surrounding informed consent and the potential for unexpected anatomical variations during a complex procedure. The challenge lies in ensuring that the patient’s autonomy is respected while also mitigating risks associated with unforeseen anatomical findings that could impact the surgical plan and patient outcomes. Careful judgment is required to navigate the grey area between standard consent and the need for emergent intraoperative decision-making. The best professional practice involves a comprehensive pre-operative discussion that anticipates potential anatomical variations and their implications. This approach ensures the patient is adequately informed about the range of possibilities, including the need for potential modifications to the surgical plan based on intraoperative findings. Specifically, the surgeon should have discussed the possibility of aberrant vascular structures or unusual nerve pathways in the target region, explaining how such findings might necessitate a change in surgical approach, the use of alternative techniques, or even a staged procedure. This proactive communication respects patient autonomy by allowing them to make informed decisions about their care, even for hypothetical scenarios. Furthermore, it aligns with ethical principles of beneficence and non-maleficence by preparing the patient for potential complexities and ensuring that any deviation from the initial plan is grounded in a prior, albeit hypothetical, consent. Failing to adequately discuss the potential for significant anatomical variations and their impact on the surgical plan represents a failure in the informed consent process. This approach, which relies solely on the initial consent for the planned procedure without addressing foreseeable but unconfirmed anatomical anomalies, breaches the ethical duty to ensure patient understanding and autonomy. It also risks violating regulatory guidelines that mandate thorough pre-operative assessment and patient education. Another unacceptable approach is to proceed with a significantly altered surgical plan without any attempt to re-engage the patient or their surrogate, even if the deviation is deemed necessary for patient safety. While intraoperative emergencies can necessitate rapid decisions, a complete disregard for re-consultation or notification, when feasible, undermines the principle of shared decision-making and patient rights. This can lead to ethical and legal repercussions, as it bypasses the patient’s right to be informed about substantial changes to their treatment. Finally, delaying the procedure to obtain a completely new, detailed consent for every minor anatomical variation encountered intraoperatively, without prior discussion of such possibilities, is often impractical and can compromise patient outcomes. While thoroughness is important, an overly rigid approach to consent in dynamic surgical environments can lead to unnecessary delays and increased patient risk, failing to balance the principles of autonomy with beneficence. Professionals should employ a decision-making framework that prioritizes comprehensive pre-operative risk assessment and transparent communication. This involves anticipating potential intraoperative challenges, including anatomical variations, and discussing these possibilities with the patient in a clear and understandable manner. The framework should also include protocols for managing emergent situations, outlining when and how to re-engage the patient or their surrogate if significant deviations from the anticipated surgical course occur, ensuring that patient autonomy and safety are continuously upheld.

Scenario Analysis: This scenario presents a professionally challenging situation due to the inherent risks associated with neurosurgical interventions, particularly in functional neurosurgery where precision and patient safety are paramount. The challenge lies in balancing the potential benefits of a novel surgical technique against the unknown risks and the need for robust evidence to support its widespread adoption. Careful judgment is required to ensure that patient welfare is prioritized, ethical guidelines are adhered to, and that the pursuit of innovation does not compromise established standards of care or regulatory compliance. The decision-making process must navigate the complexities of informed consent, institutional review board (IRB) approval, and the ethical imperative to avoid exposing patients to undue harm. Correct Approach Analysis: The best professional practice involves a rigorous, multi-stage approach to risk assessment and mitigation before considering the widespread application of a novel surgical technique. This begins with comprehensive preclinical research, including extensive laboratory studies and animal models, to understand the fundamental safety and efficacy of the technique. Following this, a carefully designed, prospective clinical trial, overseen by an Institutional Review Board (IRB) and adhering to Good Clinical Practice (GCP) guidelines, is essential. This trial must have clearly defined inclusion and exclusion criteria, robust outcome measures, and a detailed plan for monitoring adverse events. Informed consent must be exceptionally thorough, ensuring patients fully understand the experimental nature of the procedure, potential risks, and alternatives. Post-market surveillance and ongoing data collection are also critical to track long-term outcomes and identify any unforeseen complications. This systematic, evidence-based approach aligns with regulatory frameworks (e.g., FDA regulations in the US for medical devices and investigational new drugs) and ethical principles that mandate patient safety and the responsible advancement of medical knowledge. Incorrect Approaches Analysis: Adopting a novel technique based solely on anecdotal evidence from a few successful cases, without systematic preclinical or clinical validation, represents a significant ethical and regulatory failure. This approach bypasses the crucial steps of risk assessment and evidence generation, potentially exposing patients to unknown dangers and violating the principle of non-maleficence. It also fails to meet the requirements of regulatory bodies that mandate proof of safety and efficacy before widespread clinical use. Implementing a new technique based on the surgeon’s personal experience and intuition, without formal IRB oversight or a structured research protocol, is also professionally unacceptable. This approach neglects the collective responsibility for patient safety and the scientific rigor required to validate new medical interventions. It undermines the ethical obligation to protect vulnerable patients and disregards the regulatory necessity for independent ethical review and approval of research involving human subjects. Relying on the availability of the technique in a limited number of other institutions as justification for its adoption, without independent risk assessment and validation, is another flawed strategy. While peer experience can be informative, it does not substitute for a thorough, institution-specific evaluation of risks and benefits. This approach risks propagating potentially unvalidated or inadequately assessed techniques, failing to uphold the highest standards of patient care and regulatory compliance. Professional Reasoning: Professionals should employ a systematic, evidence-based decision-making process when considering novel surgical techniques. This process begins with a thorough literature review and an assessment of preclinical data. If promising, the next step is to design and obtain IRB approval for a well-controlled clinical trial. Throughout this process, open communication with patients regarding the experimental nature of the intervention and obtaining truly informed consent are paramount. Continuous monitoring of outcomes and adverse events, both during and after the trial, is essential for ongoing risk assessment and refinement of the technique. Adherence to all relevant regulatory guidelines (e.g., FDA, institutional policies) and ethical principles (e.g., beneficence, non-maleficence, autonomy) forms the bedrock of responsible innovation in functional neurosurgery.

The assessment process reveals a critical juncture for a fellowship candidate facing potential program failure. This scenario is professionally challenging because it requires balancing the program’s commitment to rigorous standards and patient safety with the ethical obligation to provide fair and transparent evaluation, and support for trainees. The fellowship director must navigate the program’s established blueprint weighting, scoring, and retake policies, ensuring adherence while also considering individual circumstances and the overall goals of training. Careful judgment is required to avoid arbitrary decisions that could undermine the integrity of the program or unfairly penalize a promising surgeon. The best approach involves a thorough review of the candidate’s performance against the established blueprint, a clear articulation of the deficiencies, and a structured remediation plan aligned with the program’s retake policies. This includes consulting the program director and relevant faculty to ensure a consistent and fair application of the rules. The program’s blueprint, which outlines the weighting of various assessment components and the scoring criteria, serves as the foundational document for evaluating performance. When a candidate falls short, the established retake policy, which should be clearly communicated to all fellows, dictates the process for remediation and re-evaluation. This approach ensures objectivity, fairness, and adherence to the program’s governance, upholding the standards of the fellowship and protecting patient welfare. It also provides the candidate with a clear path forward, demonstrating the program’s commitment to their development within defined parameters. An incorrect approach would be to unilaterally alter the scoring or weighting of assessment components to accommodate the candidate’s performance. This undermines the integrity of the blueprint, which is designed to provide an objective measure of competency across all fellows. Such an action would be ethically questionable, as it creates an unfair advantage for one individual and compromises the program’s commitment to standardized evaluation. Another incorrect approach would be to immediately dismiss the candidate without offering a structured remediation or retake opportunity, especially if the program’s policies allow for such pathways. This fails to uphold the ethical principle of providing trainees with opportunities for improvement and could be seen as a failure to adequately support the fellow’s development, potentially violating institutional guidelines on progressive discipline and remediation. A further incorrect approach would be to delay communication of the deficiencies and the implications for the candidate’s standing. This lack of transparency and timely feedback prevents the candidate from understanding the severity of their situation and from engaging in effective remediation, thereby failing to meet ethical obligations for clear and constructive feedback. Professionals should employ a decision-making framework that prioritizes transparency, fairness, and adherence to established policies. This involves: 1) clearly understanding the program’s blueprint, scoring, and retake policies; 2) objectively assessing the candidate’s performance against these established criteria; 3) engaging in open and honest communication with the candidate regarding their performance and the consequences; 4) developing and implementing a remediation plan in accordance with program policy; and 5) consulting with program leadership and relevant committees to ensure consistent and ethical application of policies.

The assessment process reveals a scenario that is professionally challenging due to the inherent risks associated with deep brain stimulation (DBS) lead placement, specifically the potential for intraoperative hemorrhage. Careful judgment is required to balance the immediate need for surgical intervention with the long-term implications for patient safety and the integrity of the surgical record. The best professional approach involves immediate cessation of the procedure upon identification of the complication, followed by prompt and thorough intraoperative management to control the bleeding. This includes obtaining appropriate imaging to delineate the extent of the hemorrhage and consulting with relevant specialists, such as neuroradiology and neurocritical care, to guide further management. Documentation of the event, the interventions taken, and the rationale behind those decisions is paramount. This approach aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as professional standards for managing surgical complications. It also ensures accurate and transparent record-keeping, which is crucial for patient care continuity and potential future legal or ethical review. An incorrect approach would be to proceed with lead implantation despite the identified hemorrhage, rationalizing that the bleeding might be minor or could be managed postoperatively. This fails to acknowledge the immediate risk of further neurological injury or expansion of the hematoma, directly violating the principle of non-maleficence. It also demonstrates a disregard for the importance of intraoperative control of critical events, potentially leading to irreversible damage. Furthermore, continuing the procedure without addressing the hemorrhage compromises the integrity of the surgical record by omitting or downplaying a significant intraoperative event. Another incorrect approach would be to terminate the procedure abruptly without adequate intraoperative management or consultation, and then to delay comprehensive documentation. This would be professionally unacceptable as it abandons the patient in a critical state and fails to provide the necessary information for subsequent care. The lack of immediate, expert consultation and management of the hemorrhage would be a failure of beneficence, and the delayed documentation would be a breach of professional responsibility and potentially regulatory requirements for accurate medical records. A further incorrect approach would be to attempt to manage the hemorrhage solely with conservative measures without obtaining further imaging or specialist input, and then to proceed with lead placement. While conservative measures may be part of the management, failing to adequately assess the extent of the hemorrhage through imaging and failing to consult with specialists represents a failure to employ best practices in managing a serious complication. This could lead to inadequate treatment of the hemorrhage, increasing the risk of neurological deficits, and would be a deviation from the standard of care expected in managing such events. The professional reasoning framework for similar situations should involve a systematic approach to complication identification and management. This includes: 1) immediate recognition and assessment of the complication; 2) halting the offending procedure if necessary; 3) activating the appropriate team for consultation and management (e.g., neuroradiology, neurocritical care); 4) implementing evidence-based interventions to mitigate harm; 5) thorough and accurate documentation of the event, management, and rationale; and 6) post-event review to identify learning opportunities and improve future practice.