Impact of a Daily Huddle on Safety in Perioperative Services

IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Joint Commission journal on quality and patient safety Pub Date : 2024-05-01 DOI:10.1016/j.jcjq.2024.04.012
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Abstract

Background

Communication failures contribute to quality gaps and may lead to serious safety events (SSEs) in the operating room (OR). Our perioperative services team experienced an increased rate of SSEs in 2020. Event analysis revealed clustered causes: communication failures and lack of timely information to prepare for cases. Consequently, the team implemented a daily morning OR safety huddle conducted before bringing patients into the OR to reduce quality gaps and improve communication.

Methods

The attending surgeon and anesthesiologist, circulating nurse, and scrub staff are required to be present. Cases are discussed using a standard format designed by the OR team with built-in time for questions and clarifications. The surgeon initiates the huddle; the circulating nurse leads and records the discussion. OR leadership initially performed daily audits but gradually reduced them when huddles became standard operating procedure (SOP). SSEs were recorded from December 2015 to September 2020 preintervention and October 2020 to July 2023 postintervention.

Results

Following the implementation of huddles, there were no SSEs for more than 900 days (2.0 SSEs/year preintervention vs. 0.0 SSEs/year postintervention). The first SSE during the postintervention period occurred in March 2023. Huddle compliance was consistently > 95%. No delays were observed in first-case on-time starts postintervention. The huddle is now SOP for all general OR teams and interventional radiology.

Conclusion

Implementing the morning safety huddle contributed to a reduction in the rate of SSEs without introducing delays to first-case start-times.

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围术期服务中每日例会对安全的影响
背景沟通失败会造成质量差距,并可能导致手术室(OR)发生严重安全事件(SSE)。我们的围手术期服务团队在 2020 年经历了严重安全事件率的上升。事件分析表明,其原因主要集中在:沟通失败和缺乏及时的信息来准备病例。因此,团队实施了每天早上将患者送入手术室前的手术室安全会议,以减少质量差距并改善沟通。病例讨论采用手术室团队设计的标准格式,并留有提问和澄清的时间。外科医生发起讨论;循环护士引导并记录讨论内容。手术室领导最初每天都进行审核,但当小组讨论成为标准操作程序(SOP)后,审核次数逐渐减少。在干预前的 2015 年 12 月至 2020 年 9 月和干预后的 2020 年 10 月至 2023 年 7 月期间记录了 SSE。结果在实施分组讨论后,超过 900 天没有发生 SSE(干预前为 2.0 SSE/年,干预后为 0.0 SSE/年)。干预后的首次 SSE 发生在 2023 年 3 月。Huddle 合规性始终保持在 95%。干预后,未观察到首例按时启动的延迟。结论实施晨间安全小组讨论有助于降低 SSE 发生率,同时不会延误首例手术的准时开始时间。
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来源期刊
CiteScore
3.80
自引率
4.30%
发文量
116
审稿时长
49 days
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Table of Contents Editorial Board The Joint Commission Journal on Quality and Patient Safety 50th Anniversary Article Collections: 50 Most Cited Table of Contents Editorial Board
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