Highlights
- •Medical safety huddles are a novel strategy to engage rehabilitation physicians.
- •Huddles increase situational awareness of anticipated safety issues.
- •Huddles supplement preexisting patient safety strategies with the medical perspective.
Abstract
Objective
To describe the implementation process, outcomes, and lessons learned in the implementation
of medical safety huddles, a novel patient safety monitoring strategy that promotes
physician engagement with patient safety.
Design
Single-center observational study.
Setting
Brain and spinal cord injury rehabilitation program at an urban, academic adult rehabilitation
hospital.
Participants
Physicians associated with the program (N=18).
Interventions
Weekly physicians' safety huddles were implemented to review, anticipate, and address
patient safety issues.
Main Outcome Measures
Main outcome measures were the number and nature of identified and anticipated patient
safety incidents, actions taken, and physician attendance during huddles. The number
of adverse events in the program before and after huddle implementation were secondary
measures.
Results
Over a 7-month period, average physician attendance at medical huddles was 76.0%.
There were 1.0±0.8 patient safety incidents and 3.2±2.1 anticipated patient safety
issues identified in each weekly huddle. Most patient safety incidents identified
were clinical administrative and clinical process related, which differed from information
gathered from the organization's preexisting patient safety monitoring strategies.
A total of 79 actions, or 3.3±1.8 actions per huddle, were taken in response to improve
patient safety for the program. Adverse events decreased from 31.2 (95% confidence
interval [CI], 27.0–35.3) to 22.9 per month (95% CI, 19.3–26.5) after implementation.
Conclusions
Medical safety huddles are a novel strategy to engage physicians in patient safety
and organizational quality improvement. They have the potential to enhance organizational
anticipation of safety risks by supplementing existing methods. Other rehabilitation
settings may wish to consider implementing and evaluating similar huddles into their
existing patient safety and quality improvement frameworks.
Keywords
List of abbreviations:
CI (confidence interval), TRI (Toronto Rehabilitation Institute), UHN (University Health Network)To read this article in full you will need to make a payment
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References
- Conceptual Framework for the International Classification for Patient Safety. Version 1.1.(Available at:) (Accessed March 25, 2017)
- Department of Health and Human Services: adverse events in rehabilitation hospitals: national incidence among Medicare beneficiaries.Department of Health and Human Services, Washington2016
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- Safety huddles to proactively identify and address electronic health record safety.J Am Med Inform Assoc. 2016; 24: 261-267
- Engaging physicians in a shared quality agenda.(Available at:) (Accessed March 25, 2017)
- Canadian incident analysis framework.(Available at:)www.patientsafetyinstitute.ca(Accessed March 25, 2017)Date: 2012
- The elephant of patient safety: what you see depends on how you look.Jt Comm J Qual Patient Saf. 2010; 36: 399-401
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Article info
Publication history
Published online: October 10, 2017
Footnotes
Disclosures: none.
Identification
Copyright
© 2017 by the American Congress of Rehabilitation Medicine
