Safety in numbers
UF Health staff huddles improve communication, address safety issues and ensure information is shared.
A few minutes of focused discussion can save a life or prevent serious harm to a hospital patient.
For dozens of clinical staff serving our patients, that means gathering early every weekday in a sprawling lecture hall for a patient safety huddle. On one recent morning, the day’s only safety issue was relatively straightforward: A patient had been caught smoking in their room. A brief discussion followed, giving details about how the problem was settled. On other days, the issues are more complex — a potential medication error that was caught before it reached the patient or how to better handle the cleanup when a chemotherapy drug is spilled.
Safety huddles aren’t limited to this large group. Individual nursing units do their own safety huddle during every shift. The hospital pharmacy has a daily safety huddle and other departments hold them regularly.
The safety huddles are as simple as they are effective: Bring managers andstaff from throughout UF Health Shands together for a multidisciplinary meeting. Talk about safety issues that occurred in the past 24 hours, and ones that could arise in the coming days. Then discuss how the problem was addressed. The most important step comes last: Make sure the day’s safety issues — and how they were resolved — get communicated quickly to the staff. Managers and directors share important information with their staff after the safety huddle via email.
“The most important thing is that safety huddles allow us to take care of issues immediately. It’s a very focused effort addressing what happened in the past 24 hours and how we can positively affect it,” said Irene Alexaitis, D.N.P., R.N., UF Health Shands chief nursing officer and Nursing and Patient Services vice president.
Since the huddles began at UF Health Shands in February 2014, the reporting of patient-safety events increased by 52 percent. Serious safety events dropped by 82 percent and reportable adverse events are down 70 percent. Leaders say that’s no coincidence, particularly because safety huddles help spread vital information quickly.
“The more things we catch when they’re a relatively minor event, the better chance we have of preventing a major event later. Safety huddles help us do that,” said Diana Richardson, M.B.A., UF Health Shands Operations vice president.
Safety huddles work well because they facilitate vital activities, including communication, cooperation, idea sharing and problem-solving. In a facility as large as UF Health Shands, one department or unit might not always be aware of a safety issue that arose elsewhere in the hospital. That’s where the safety huddles come in, propelling the flow of vital information and extending its reach.
The huddles are part of a broader effort to encourage more reporting of safety issues, said Sue Keating, the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety’s Clinical Risk Management director. The rise in reporting safety incidents has created a “safety first” culture where everyone is empowered to speak up. That, Keating said, creates an even safer environment for patients and staff.
“Everyone now has a bigger-picture view of safety issues elsewhere in the hospital, as well as how to prevent safety problems in their unit,” she said.
Alexaitis said the safety huddles have been especially effective at creating transparency and allowing everyone to learn how to improve after an error occurs. Whether the issue is a patient fall or the best way to clean up a chemotherapy drug spill, the huddles make the hospital more efficient in managing safety issues.
Making the safety huddles more inclusive has also paid off. During the early morning safety huddle, managers used to be the ones talking about patient falls and how to prevent them. When nurses and other staff who work directly with patients were brought into the huddles, new ideas such as using gait belts more often emerged.
“There have been some wonderful ideas from the front-line staff. We never would have had that if they weren’t brought in to the discussion,” Alexaitis said.
Likewise, safety huddles help the faculty and staff deal with safety issues before they affect a patient or become problematic.
“It gives us a forum where everyone can talk about near misses,” Alexaitis said. “Then, we can put improvements in place before they become more significant.”
