University of Pittsburgh Medical Center Children's Hospital of Pittsburgh , Pittsburgh, Pennsylvania.
Adv Neonatal Care. 2024 Oct 1;24(5):393-399. doi: 10.1097/ANC.0000000000001180. Epub 2024 Aug 27.
Huddles are brief team meetings designed to communicate essential information. Safety huddles provide a forum to identify and review patient safety events. In a just culture, everyone is accountable for patient safety.
The purpose of this project is to discuss safety issues/events at the twice daily bed capacity huddles in a Level IV Neonatal Intensive Care Unit (NICU) utilizing a just culture model. Having daily discussions of patient safety and the escalation process for follow-up promotes a just culture. The aims are to improve the unit's culture of safety and learn from patient safety issues.
A just culture model was adopted to promote discussion of safety events during the huddles. A structured checklist of safety events was utilized along with a script of ground rules. Twice a day, a multidisciplinary group gathers to huddle. Nurse leaders facilitate the discussion, track the results, and provide follow-up.
The structured safety huddle began in May of 2020 and continues twice daily. All required staff attend. The escalation process is defined and has prevented recurrence of some safety issues. The NICU experienced a 14% increase in favorable results on the Agency for Healthcare Research and Quality (AHRQ) culture of safety survey since the inception of the structured safety huddles.
Safety huddle discussions have impacted the culture of safety on this unit. Tracking of discussions can help to identify trends, improve processes, and impact patient safety.
小组讨论是一种简短的团队会议，旨在交流重要信息。安全小组讨论为识别和审查患者安全事件提供了一个论坛。在公正文化中，每个人都对患者安全负责。
本项目旨在利用公正文化模式讨论四级新生儿重症监护病房（NICU）中每日两次的床位容量小组讨论中的安全问题/事件。每日讨论患者安全问题和升级后续跟踪程序可促进公正文化的发展。目标是提高单位的安全文化，并从患者安全问题中吸取教训。
采用公正文化模式促进小组讨论中的安全事件讨论。使用安全事件的结构化检查表和基本规则脚本。每天两次，一个多学科小组聚集在一起进行小组讨论。护士领导负责促进讨论、跟踪结果并提供后续行动。
结构化的安全小组讨论于 2020 年 5 月开始，每天进行两次。所有必需的员工都参加。已经定义了升级程序，并且已经防止了一些安全问题的再次发生。自从实施结构化安全小组讨论以来，NICU 在医疗保健研究和质量局（AHRQ）安全文化调查中的有利结果增加了 14%。
安全小组讨论已经影响了这个单位的安全文化。对讨论的跟踪可以帮助识别趋势、改进流程并影响患者安全。
