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Risk managers and clinicians are finding that huddles are an effective way to improve patient safety and identify deficiencies, but there is little guidance on how to conduct them. Experienced huddlers say a formal plan for the huddle will yield more valuable results.
A huddle is a gathering of involved and interested personnel soon after a patient safety event to discuss what happened, why it happened and how the problem might be prevented. They have been used for all manner of patient safety issues, and Nationwide Children’s Hospital (NCH) in Columbus, OH, has found them to be especially effective with medication events, says Shelly Morvay, PharmD, medication safety pharmacist at the hospital.
Huddles helped decrease the absolute number of harmful adverse drug events (ADEs) by 74%, and the ADE rate per 1,000 dispensed doses decreased by 85%, Morvay says. ADEs are defined as injuries resulting from medical care involving medication use.
NCH has conducted more than 800 medication event huddles over three years and identified more than 3,000 improvements. ADEs accounted for approximately two-thirds of reported patient harm at NCH.
The quick-investigation huddle tool was proposed as a means to engage frontline staff in identifying process improvements that might contribute to ADE elimination, Morvay says. In March 2010, NCH piloted the medication event huddle process in its critical care units, and in 2011, it introduced the process to all inpatient units and some ambulatory clinics. Subsequently, NCH has spread the process to ADEs that occur anywhere in the organization, including all ambulatory clinics, the emergency department, perioperative areas, and interventional radiology.
NCH’s success with the huddles yielded some information about what makes them productive. Responding the ADE quickly was a prime concern; the 30-minute medication event huddles were initiated and scheduled within 24 hours whenever an ADE was identified. The essential components of the huddle included:
• an explanation by the core huddle team leader of the huddle process;
• simulation of the ADE using the actual electronic medical record, infusion pump, pharmacy labels, and other equipment or supplies;
• review of a standard list of questions to identify environmental or practice factors that may have contributed;
• assignment of identified interventions or "tests of change" to appropriate participants;
• follow-up communication about "tests of change" via email;
• encouragement to speak with colleagues about the specific ADE and huddle experience.
In addition, the medication event huddles were used as an opportunity to promote a culture of safety, increase involvement of frontline staff, and speed improvement efforts, says Clinical Coordinator Dorcas Lewe, RN, MS, who worked closely with Morvay on the huddles. Morvay and Lewe estimate that medication event huddles require a minimum of 0.5 full-time equivalent (FTE) nurses to review the ADEs, schedule the huddles, and follow up on completion of recommendations. While huddles do not replace a formal root cause analysis (RCA) or daily safety walkarounds by leaders, they do enable a more rapid identification of the cause and subsequent intervention, they say.
Huddles should be conducted by a core group of interdisciplinary representatives, Morvay says. The other people in the huddle should include frontline staff who were involved with the incident or are familiar with it, along with unit leaders. Staff members are reminded that the huddle is a brainstorming session and not intended to single out any person as responsible for the event.
"We encourage them to be honest about what they think occurred," Lewe says. "They are always informed about the huddles by their managers so that it is coming from someone they know. It’s not a call from administration."
Managers know that they are free to forward the huddle invitation to anyone else that might contribute useful information, Lewe says. After the brainstorming in the huddle, any necessary interventions are assigned to specific huddle attendees.
Risk manager Carol McGlone, RN, says the huddles have become a valuable asset in the hospital’s overall patient safety program. One of the benefits is that huddles produce useful information much faster than a full RCA, which comes later.
"We have seen over time that staff will report an incident or a near-miss and suggest a huddle is appropriate, rather than waiting for leadership to call a huddle. This is true of events that do not involve medication safety, so that tells me that the staff see the value of huddles and appreciate the opportunity to give input," McGlone says.
McGlone participates in some huddles at NCH, collaborating closely with the quality improvement department and clinical leaders.
NCH conducts medication safety huddles once or twice per weekday, as warranted, Lewe says. The hospital uses certain criteria to determine when a huddle is appropriate, but staff members are free to request a huddle even when those criteria are not met, she says. The criteria for calling a huddle include the need for intervention or additional monitoring, severity of an event, and incidents involving high alert medications or specific focus areas such as medication reconciliation. A huddle also is called when there is a misstep or near-miss when implementing a new policy.
A summary of the information gleaned from the huddle is shared through Microsoft’s Sharepoint software to everyone who attended the huddle and those who were invited but could not come. Any huddle attendee who was assigned an intervention also receives a recap of the action needed and when it should be completed, along with frequent reminders until it is done.
The huddle soon will be implemented in the hospital’s employee safety program, McGlone says.
At South Nassau Communities Hospital in Oceanside, NY, huddles are used routinely for everything from planning the day on a unit to serious adverse events, says Ruth Ragusa, RN, vice president of organizational effectiveness. She has found that the timing for a huddle must be tailored to the individual event. Some should be held as soon as possible, before people forget the important details, while others might be delayed for a day.
"With some incidents, the staff are still dealing with it, and you can’t pull them away from patient care," she says. "We also try to let the staff diffuse their feelings about it, because sometimes it can be upsetting to them and they need a breather before you ask them to recount the incident."