Safety huddles to proactively identify and address electronic health record safety.
ABSTRACT: Objective:Methods to identify and study safety risks of electronic health records (EHRs) are underdeveloped and largely depend on limited end-user reports. "Safety huddles" have been found useful in creating a sense of collective situational awareness that increases an organization's capacity to respond to safety concerns. We explored the use of safety huddles for identifying and learning about EHR-related safety concerns. Design:Data were obtained from daily safety huddle briefing notes recorded at a single midsized tertiary-care hospital in the United States over 1 year. Huddles were attended by key administrative, clinical, and information technology staff. We conducted a content analysis of huddle notes to identify what EHR-related safety concerns were discussed. We expanded a previously developed EHR-related error taxonomy to categorize types of EHR-related safety concerns recorded in the notes. Results:On review of daily huddle notes spanning 249 days, we identified 245 EHR-related safety concerns. For our analysis, we defined EHR technology to include a specific EHR functionality, an entire clinical software application, or the hardware system. Most concerns (41.6%) involved " EHR technology working incorrectly, " followed by 25.7% involving " EHR technology not working at all. " Concerns related to "EHR technology missing or absent" accounted for 16.7%, whereas 15.9% were linked to " user errors ." Conclusions:Safety huddles promoted discussion of several technology-related issues at the organization level and can serve as a promising technique to identify and address EHR-related safety concerns. Based on our findings, we recommend that health care organizations consider huddles as a strategy to promote understanding and improvement of EHR safety.
Project description:<h4>Background</h4>Conducting post-fall huddles is considered an integral component of a fall-risk-reduction program. However, there is no evidence linking post-fall huddles to patient outcomes or perceptions of teamwork and safety culture. The purpose of this study is to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture.<h4>Methods</h4>During a two-year demonstration project, we developed a system for 16 small rural hospitals to report, benchmark, and learn from fall events, and we trained them to conduct post-fall huddles. To calculate a hospital's repeat fall rate, we divided the total number of falls reported by the hospital by the number of unique medical record numbers associated with each fall. We used Spearman correlations with exact P values to determine the association between the proportion of falls followed by a huddle and the repeat fall rate. At study end, we used the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) to assess perceptions of teamwork support for fall-risk reduction and the Hospital Survey on Patient Safety Culture (HSOPS) to assess perceptions of safety culture. We added an item to the T-TPQ for respondents to indicate the number of post-fall huddles in which they had participated. We used a binary logistic regression with a logit link to examine the effect of participation in post-fall huddles on respondent-level percent positive T-TPQ and HSOPS scores. We accounted for clustering of respondents within hospitals with random effects using the GLIMMIX procedure in SAS/STAT.<h4>Result</h4>Repeat fall rates were negatively associated with the proportion of falls followed by a huddle. As compared to hospital staff who did not participate in huddles, those who participated in huddles had more positive perceptions of four domains of safety culture and how team structure, team leadership, and situation monitoring supported fall-risk reduction.<h4>Conclusions</h4>Post-fall huddles may reduce the risk of repeat falls. Staff who participate in post-fall huddles are likely to have positive perceptions of teamwork support for fall-risk reduction and safety culture because huddles are a team-based approach to reporting, adapting, and learning.
Project description:<h4>Background</h4>The Patient Safety Huddle (PSH) is a brief multidisciplinary daily meeting held to discuss threats to patient safety and actions to mitigate risk. Despite growing interest and application of huddles as a mechanism for improving safety, evidence of their impact remains limited. There is also variation in how huddles are conceived and implemented with insufficient focus on their fidelity (the extent to which delivered as planned) and potential ways in which they might influence outcomes. The Huddle Up for Safer Healthcare (HUSH) project attempted to scale up the implementation of patient safety huddles (PSHs) in five hospitals - 92 wards - across three UK NHS Trusts. This paper aims to assess their fidelity, time to embed, and impact on teamwork and safety culture.<h4>Methods</h4>A multi-method Developmental Evaluation was conducted. The Stages of Implementation Checklist (SIC) was used to determine time taken to embed PSHs. Observations were used to check embedded status and fidelity of PSH. A Teamwork and Safety Climate survey (TSC) was administered at two time-points: pre- and post-embedding. Changes in TSC scores were calculated for Trusts, job role and clinical speciality.<h4>Results</h4>Observations confirmed PSHs were embedded in 64 wards. Mean fidelity score was 4.9/9. PSHs frequently demonstrated a 'fear free' space while Statistical Process Control charts and historical harms were routinely omitted. Analysis showed a positive change for the majority (26/27) of TSC questions and the overall safety grade of the ward.<h4>Conclusions</h4>PSHs are feasible and effective for improving teamwork and safety culture, especially for nurses. PSH fidelity criteria may need adjusting to include factors deemed most useful by frontline staff. Future work should examine inter-disciplinary and role-based differences in TSC outcomes.
Project description:<h4>Objectives</h4>To analyse the language and conversation used in huddles to gain a deeper understanding of exactly how huddles proceed in practice and to examine the methods by which staff members identify at-risk patients.<h4>Setting</h4>Paediatric wards in four English hospitals, which were part of a 12-hospital cohort participating in the Situation Awareness for Everyone programme. Wards varied by geographical region and type of hospital.<h4>Participants</h4>Paediatric staff on wards in four English hospitals.<h4>Design</h4>Ethnomethodology and conversation analysis of recorded safety huddles.<h4>Methods</h4>This study represents the first analysis of huddle interaction. All huddle meetings taking place on four wards across four different hospitals were audio recorded and transcribed. The research question examined was: how are staff identifying at-risk patients in huddles? The ethnomethodological conversation analytic approach was used to analyse the transcripts.<h4>Results</h4>Huddlers made use of categories that allowed them to efficiently identify patients for each other as needing increased attention. Lexicon included the use of 'no concerns', 'the one to watch', 'watcher' and 'acute concerns'. Huddlers used the meetings to go beyond standardised indicators of risk to identify relative risk and movement in patients towards deterioration, relative to the last huddle meeting and to their usual practices. An implicit category, termed here 'pre-concerns', was used by staff to identify such in-between states. Sequential analysis also highlighted the conversational rights that were held implicitly by staff in different clinical roles.<h4>Conclusion</h4>Practical implications and recommendations for huddlers are considered. These included that for increased situation awareness, it is recommended that all staff are active in the huddle conversation and not only the most senior team members.
Project description:Individuals with more or stronger social bonds experience enhanced survival and reproduction in various species, though the mechanisms mediating these effects are unclear. Social thermoregulation is a common behaviour across many species which reduces cold stress exposure, body heat loss, and homeostatic energy costs, allowing greater energetic investment in growth, reproduction, and survival, with larger aggregations providing greater benefits. If more social individuals form larger thermoregulation aggregations due to having more potential partners, this would provide a direct link between sociality and fitness. We conducted the first test of this hypothesis by studying social relationships and winter sleeping huddles in wild Barbary macaques (Macaca sylvanus), wherein individuals with more social partners experience greater probability of winter survival. Precipitation and low temperature increased huddle sizes, supporting previous research that huddle size influences thermoregulation and energetics. Huddling relationships were predicted by social (grooming) relationships. Individuals with more social partners therefore formed larger huddles, suggesting reduced energy expenditure and exposure to environmental stressors than less social individuals, potentially explaining how sociality affects survival in this population. This is the first evidence that social thermoregulation may be a direct proximate mechanism by which increased sociality enhances fitness, which may be widely applicable across taxa.
Project description:BACKGROUND:Patient safety is a key priority for healthcare systems. Patient safety huddles have been advocated as a way to improve safety. We explored the feasibility of huddles in general practice. METHODS:We invited all general practices in West Yorkshire to complete an online survey and interviewed practice staff. RESULTS:Thirty-four out of 306 practices (11.1%) responded to our survey. Of these, 22 practices (64.7%) reported having breaks for staff to meet and eight (23.5%) reported no longer having breaks in their practices. Seven interviewees identified several barriers to safety huddles including time and current culture; individuals felt meetings or breaks would not be easily integrated into current primary care structure. DISCUSSION:Despite their initial promise, there are major challenges to introducing patient safety huddles within the current context of UK general practice. General practice staff may need more convincing of potential benefits.
Project description:<h4>Objective</h4>A recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system.<h4>Methods</h4>The Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports.<h4>Results</h4>We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or 'hidden dependencies' within the EHR.<h4>Discussion</h4>EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after 'go-live' and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA.<h4>Conclusions</h4>Because EHR-related safety concerns have complex sociotechnical origins, institutions with long-standing as well as recent EHR implementations should build a robust infrastructure to monitor and learn from them.
Project description:BACKGROUND:Studies show that implementing huddles in healthcare can improve a variety of outcomes. Yet little is known about the mechanisms through which huddles exert their effects. To help remedy this gap, our study objectives were to explore hospital administrator and frontline staff perspectives on the benefits and challenges of implementing a tiered huddle system; and propose a model based on our findings depicting the mediating pathways through which implementing a huddle system may reduce patient harm. METHODS:Using qualitative methods, we conducted semi-structured interviews and focus groups to obtain a deeper understanding of the huddle system and its outcomes as implemented in an academic tertiary care children's hospital with 539 inpatient beds. We recruited healthcare providers representing all levels using a snowball sampling technique (10 interviews), and emails, flyers, and paper invitations (six focus groups). We transcribed recordings and analysed the data using established techniques. RESULTS:Five themes emerged and provided the foundational constructs of our model. Specifically we propose that huddle implementation leads to improved efficiencies and quality of information sharing, increased levels of accountability, empowerment, and sense of community, which together create a culture of collaboration and collegiality that increases the staff's quality of collective awareness and enhanced capacity for eliminating patient harm. CONCLUSIONS:While each construct in the proposed model is itself a beneficial outcome of implementing huddles, conceptualising the pathways by which they may work allows us to design ways to evaluate other huddle implementation efforts designed to help reduce failures and eliminate patient harm.
Project description:<h4>Background</h4>As the COVID-19 vaccination campaign unfolds, it is important to continuously assess the real world safety of FDA-authorized vaccines. Curation of large-scale electronic health records (EHRs) enables near real-time safety evaluations that were not previously possible.<h4>Methods</h4>In this retrospective study, we deployed deep neural networks over a large EHR system to automatically curate the adverse effects mentioned by physicians in over 1.2 million clinical notes between December 1<sup>st</sup> 2020 and April 20<sup>th</sup> 2021. We compared notes from 68,266 individuals who received at least one dose of BNT162b2 (n = 51,795) or mRNA-1273 (n = 16,471) to notes from 68,266 unvaccinated individuals who were matched by demographic, geographic, and clinical features.<h4>Findings</h4>Individuals vaccinated with BNT162b2 or mRNA-1273 had a higher rate of return to the clinic, but not the emergency department, after both doses compared to unvaccinated controls. The most frequently documented adverse effects within 7 days of each vaccine dose included myalgia, headache, and fatigue, but the rates of EHR documentation for each side effect were remarkably low compared to those derived from active solicitation during clinical trials. Severe events including anaphylaxis, facial paralysis, and cerebral venous sinus thrombosis were rare and occurred at similar frequencies in vaccinated and unvaccinated individuals.<h4>Conclusions</h4>This analysis of vaccine-related adverse effects from over 1.2 million EHR notes of more than 130,000 individuals reaffirms the safety and tolerability of the FDA-authorized mRNA COVID-19 vaccines in practice.
Project description:BACKGROUND:Team-based care has been identified as a key component in transforming primary care. An important factor in implementing team-based care is the requirement for teams to have daily huddles. During huddles, the care team, comprising physicians, nurses, and administrative staff, come together to discuss their daily schedules, track problems, and develop countermeasures to fix these problems. However, the impact of these huddles on staff burnout over time and patient outcomes are not clear. Further, there are challenges to implementing huddles in fast-paced primary care clinics. We will test whether the impact of a behavioral intervention of leadership training and problem-solving during the daily huddling process will result in higher consistent huddling in the intervention arm and result in higher team morale, reduced burnout, and improved patient outcomes. METHODS/DESIGN:We will conduct a care-team-level cluster randomized trial within primary care practices in two Midwestern states. The intervention will comprise a 1-day training retreat for leaders of primary care teams, biweekly sessions between huddle optimization coaches and members of the primary care teams, as well as coaching site visits at 30 and 100 days post intervention. This behavioral intervention will be compared to standard care, in which care teams have huddles without any support or training. Surveys of primary care team members will be administered at baseline (prior to training), 100 days (for the intervention arm only), and 180 days to assess team dynamics. The primary outcome of this trial will be team morale. Secondary outcomes will assess the impact of this intervention on clinician burnout, patient satisfaction, and quality of care. DISCUSSION:This trial will provide evidence on the impact of a behavioral intervention to implement huddles as a key component of team-based care models. Knowledge gained from this trial will be critical to broader deployment and successful implementation of team-based care models. TRIAL REGISTRATION:Clinicaltrials.gov , NCT03062670 . Registered on 23 February 2017.
Project description:Endotherms such as rats and mice huddle together to keep warm. The huddle is considered to be an example of a self-organising system, because complex properties of the collective group behaviour are thought to emerge spontaneously through simple interactions between individuals. Groups of rodent pups display two such emergent properties. First, huddling undergoes a 'phase transition', such that pups start to aggregate rapidly as the temperature of the environment falls below a critical temperature. Second, the huddle maintains a constant 'pup flow', where cooler pups at the periphery continually displace warmer pups at the centre. We set out to test whether these complex group behaviours can emerge spontaneously from local interactions between individuals. We designed a model using a minimal set of assumptions about how individual pups interact, by simply turning towards heat sources, and show in computer simulations that the model reproduces the first emergent property--the phase transition. However, this minimal model tends to produce an unnatural behaviour where several smaller aggregates emerge rather than one large huddle. We found that an extension of the minimal model to include heat exchange between pups allows the group to maintain one large huddle but eradicates the phase transition, whereas inclusion of an additional homeostatic term recovers the phase transition for large huddles. As an unanticipated consequence, the extended model also naturally gave rise to the second observed emergent property--a continuous pup flow. The model therefore serves as a minimal description of huddling as a self-organising system, and as an existence proof that group-level huddling dynamics emerge spontaneously through simple interactions between individuals. We derive a specific testable prediction: Increasing the capacity of the individual to generate or conserve heat will increase the range of ambient temperatures over which adaptive thermoregulatory huddling will emerge.