IHA case studies

Enhancing Hospital Safety Culture Through Use of Defect Huddle Incident Management System


Data from the AHRQ Safety Culture Survey indicated the need to improve mechanisms for incident capture, analysis, prioritization and action. Based on Lean/Six Sigma methodology, the defect huddle was designed. It is a weekly 30 minute multidisciplinary team meeting where safety events, including near misses, medication errors, harm events, complaints/grievances, sentinel and/or regulatory issues are presented and rated on a harm scale.

The resulting summary score indicates the improvement response: (1) localized departmental Plan-Do-Study-Act; (2) multidisciplinary Failure Mode Effects Analysis; or (3) formal root cause analysis. The Defect Huddle also serves as a tracking repository of safety improvement efforts through conclusion.

Data from the first six months of defect huddle indicate that 97 safety events were reviewed, with 62 percent triaged as appropriate for FMEA, 31 percent for department PDSA “just do it” corrections and 7 percent for formal root cause analysis.

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state. These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

  • Safe
  • Timely
  • Effective
  • Efficient
  • Equitable
  • Patient-centered

(The Institute of Medicine's six aims for improvement.)

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