| Peer-Reviewed

Effect of Daily Safety Briefing Huddles on the Reporting of Adverse Events and Near-misses

Received: 28 January 2019     Accepted: 14 March 2019     Published: 3 April 2019
Views:       Downloads:
Abstract

Background: Incident reporting offers valuable information regarding safety issues, but near-misses (NM) and adverse events (AE) remain underreported. DSB huddles help foster collective situational awareness that increases an organization’s capacity to respond to safety concerns. However, effects of DSB huddles on AE/NM reporting remain understudied. Objective: To examine how daily safety briefing (DSB) huddles operate in a surgical unit, and assess their impact on reporting of adverse events and near-misses. Methods: DSB huddles were piloted in a gastrointestinal surgical unit. The study compared AE/NM reporting rates and reporting types before and after adopting DSB huddles. Results: After adopting DSB huddles, AE reporting improved from 0.9% to 1.8%, and NM reporting improved from 0.5% to 7.1% (p < .05). Self-reporting of safety issues increased from 44.4% to 73.8%; NM reporting domains increased from 6 to 15. Conclusions: DSB huddles increased reporting rates of AE and of NM particularly, improved reporting dimensions of NM, and increased team members’ situational patient safety awareness.

Published in American Journal of Nursing Science (Volume 8, Issue 3)
DOI 10.11648/j.ajns.20190803.12
Page(s) 92-96
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2019. Published by Science Publishing Group

Keywords

Daily Safety Huddles, Incident Reporting, Near-misses, Risk Management, Patient Safety

References
[1] Dimova R, Stoyanova R, Doykov I. Mixed-methods study of reported clinical cases of undesirable events, medical errors, and near misses in health care. Journal of evaluation in clinical practice. 2018; 24(4):752-757.
[2] Clancy CM. Common formats allow uniform collection and reporting of patient safety data by patient safety organizations. American Journal of Medical Quality. 2010; 25(1):73-75.
[3] Chamberlain CJ, Koniaris LG, Wu AW, Pawlik TM. Disclosure of "nonharmful" medical errors and other events: duty to disclose. Arch Surg. 2012; 147(3):282-286.
[4] CJ C, LG K, AW W, TM P. Disclosure of "nonharmful" medical errors and other events: duty to disclose. Archives of Surgery. 2012; 147(3):282-286.
[5] Smith KS, Harris KM, Potters L, et al. Physician attitudes and practices related to voluntary error and near-miss reporting. Journal of Oncology Practice. 2014; 10(5): e350.
[6] Classen DC, Resar R, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff. 2011; 30(4):581-589.
[7] Yoon RS, Alaia MJ, Hutzler LH, Iii JAB. Using “Near Misses” Analysis to Prevent Wrong-Site Surgery. Journal for Healthcare Quality. 2013; 37(2):126.
[8] Menon S, Singh H, Giardina TD, et al. Safety huddles to proactively identify and address electronic health record safety. Journal of the American Medical Informatics Association. 2016: ocw153.
[9] Goldenhar LM, Brady PW, Sutcliffe KM, Muething SE. Huddling for high reliability and situation awareness. Bmj Quality & Safety. 2013; 22(11):899-906.
[10] Sediva I, Snelling L. Daily Safety Briefs (DSB) focus on improving safety at Hasbro Children's Hospital. R I Med J. 2018; 101(2):23.
[11] Hatva E. Daily Briefing Promotes Hospital-Wide Transparency And Patient Safety. Biomedical Instrumentation & Technology. 2013; 47(6):489-492.
[12] Maurette P. [To err is human: building a safer health system]. (0750-7658 (Print)).
[13] Yu KH, Nation RL, Dooley MJ. Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough? Quality & Safety in Health Care. 2005; 14(5):358-363.
[14] Hamilton EC, Pham DH, Minzenmayer AN, et al. Are we missing the near misses in the OR?—underreporting of safety incidents in pediatric surgery. Journal of Surgical Research. 2018; 221:336-342.
[15] Meeks DW, Smith MW, Taylor L, Sittig DF, Scott JM, Singh H. An analysis of electronic health record-related patient safety concerns. Journal of the American Medical Informatics Association Jamia. 2014; 21(6):1053-1059.
[16] Ashcroft DM, Morecroft C, Parker D, Noyce PR. Likelihood of reporting adverse events in community pharmacy: an experimental study. Quality & Safety in Health Care. 2006; 15(1):48.
[17] Vrbnjak D, Denieffe S, O’Gorman C, Pajnkihar M. Barriers to reporting medication errors and near misses among nurses: A systematic review. International journal of nursing studies. 2016; 63:162-178.
[18] Shojania KG, Wald H, Gross R. Understanding medical error and improving patient safety in the inpatient setting. Medical Clinics of North America. 2002; 8 6(4):847-867.
[19] Barach P, ., Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. Bmj. 2000; 320(7237):759-763.
[20] Van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to improve patient safety. Current opinion in otolaryngology & head and neck surgery. 2015; 23(4):292-296.
[21] Speroni KG, Fisher J, Dennis M, Daniel M. What causes near-misses and how are they mitigated? Plastic surgical nursing : official journal of the American Society of Plastic and Reconstructive Surgical Nurses. Jul-Sep 2014; 34(3):114-119.
[22] Larizgoitia I, Bouesseau MC, Kelley E. WHO Efforts to Promote Reporting of Adverse Events and Global Learning. Journal of Public Health Research,2,3(2013-12-01). 2013; 2(3): e29.
[23] Grant MJ, Larsen GY. Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit. Journal of Nursing Care Quality. 2007; 22(3):213-221.
Cite This Article
  • APA Style

    Minping Deng, Weiju Chen, Tianying Pang, Chunmei Lin. (2019). Effect of Daily Safety Briefing Huddles on the Reporting of Adverse Events and Near-misses. American Journal of Nursing Science, 8(3), 92-96. https://doi.org/10.11648/j.ajns.20190803.12

    Copy | Download

    ACS Style

    Minping Deng; Weiju Chen; Tianying Pang; Chunmei Lin. Effect of Daily Safety Briefing Huddles on the Reporting of Adverse Events and Near-misses. Am. J. Nurs. Sci. 2019, 8(3), 92-96. doi: 10.11648/j.ajns.20190803.12

    Copy | Download

    AMA Style

    Minping Deng, Weiju Chen, Tianying Pang, Chunmei Lin. Effect of Daily Safety Briefing Huddles on the Reporting of Adverse Events and Near-misses. Am J Nurs Sci. 2019;8(3):92-96. doi: 10.11648/j.ajns.20190803.12

    Copy | Download

  • @article{10.11648/j.ajns.20190803.12,
      author = {Minping Deng and Weiju Chen and Tianying Pang and Chunmei Lin},
      title = {Effect of Daily Safety Briefing Huddles on the Reporting of Adverse Events and Near-misses},
      journal = {American Journal of Nursing Science},
      volume = {8},
      number = {3},
      pages = {92-96},
      doi = {10.11648/j.ajns.20190803.12},
      url = {https://doi.org/10.11648/j.ajns.20190803.12},
      eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajns.20190803.12},
      abstract = {Background: Incident reporting offers valuable information regarding safety issues, but near-misses (NM) and adverse events (AE) remain underreported. DSB huddles help foster collective situational awareness that increases an organization’s capacity to respond to safety concerns. However, effects of DSB huddles on AE/NM reporting remain understudied. Objective: To examine how daily safety briefing (DSB) huddles operate in a surgical unit, and assess their impact on reporting of adverse events and near-misses. Methods: DSB huddles were piloted in a gastrointestinal surgical unit. The study compared AE/NM reporting rates and reporting types before and after adopting DSB huddles. Results: After adopting DSB huddles, AE reporting improved from 0.9% to 1.8%, and NM reporting improved from 0.5% to 7.1% (p Conclusions: DSB huddles increased reporting rates of AE and of NM particularly, improved reporting dimensions of NM, and increased team members’ situational patient safety awareness.},
     year = {2019}
    }
    

    Copy | Download

  • TY  - JOUR
    T1  - Effect of Daily Safety Briefing Huddles on the Reporting of Adverse Events and Near-misses
    AU  - Minping Deng
    AU  - Weiju Chen
    AU  - Tianying Pang
    AU  - Chunmei Lin
    Y1  - 2019/04/03
    PY  - 2019
    N1  - https://doi.org/10.11648/j.ajns.20190803.12
    DO  - 10.11648/j.ajns.20190803.12
    T2  - American Journal of Nursing Science
    JF  - American Journal of Nursing Science
    JO  - American Journal of Nursing Science
    SP  - 92
    EP  - 96
    PB  - Science Publishing Group
    SN  - 2328-5753
    UR  - https://doi.org/10.11648/j.ajns.20190803.12
    AB  - Background: Incident reporting offers valuable information regarding safety issues, but near-misses (NM) and adverse events (AE) remain underreported. DSB huddles help foster collective situational awareness that increases an organization’s capacity to respond to safety concerns. However, effects of DSB huddles on AE/NM reporting remain understudied. Objective: To examine how daily safety briefing (DSB) huddles operate in a surgical unit, and assess their impact on reporting of adverse events and near-misses. Methods: DSB huddles were piloted in a gastrointestinal surgical unit. The study compared AE/NM reporting rates and reporting types before and after adopting DSB huddles. Results: After adopting DSB huddles, AE reporting improved from 0.9% to 1.8%, and NM reporting improved from 0.5% to 7.1% (p Conclusions: DSB huddles increased reporting rates of AE and of NM particularly, improved reporting dimensions of NM, and increased team members’ situational patient safety awareness.
    VL  - 8
    IS  - 3
    ER  - 

    Copy | Download

Author Information
  • Gastrointestinal Surgical Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China

  • Department of Nursing, The First Affiliated Hospital of Jinan University, Guangzhou, China

  • Gastrointestinal Surgical Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China

  • Gastrointestinal Surgical Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China

  • Sections