Peer-to-peer problem-solving is a proven method of issue resolution. And it’s why the Vizient Patient Safety Organization (PSO) added bi-monthly huddles to its regularly scheduled safe table discussions for members. In the huddles, patient safety leaders from organizations across the country gather twice a month, via a privileged and confidential conference call, to share recent safety events and areas of concern.

“If a patient safety event can happen at one organization, it can happen at any organization,” said Ellen Flynn, RN, MBA, JD, CPPS, associate vice president, safety programs at Vizient. “The concept of the huddles is that bringing issues up to the group, almost in real-time, gives everyone the opportunity to learn how to prevent them from happening somewhere else.”

Vizient launched its pilot huddle in April 2017 with five representatives from critical access member hospitals. Two months later, the huddle was opened to all Vizient PSO members who signed the required confidentiality and non-disclosure agreements.

Recent topics discussed at the huddles have covered the impact of shortages of IV solutions and sterile water, therapeutic duplication with direct oral anticoagulants (DOACs), and issues related to escalation of care processes. “I have heard members say that they discussed a safety issue at a huddle and then were able to complete proactive risk assessments to prevent the same safety issue (patient harm) from occurring in their organizations. This demonstrates the value of the discussions and the increased awareness that can occur within a PSO membership,” said Flynn.

Huddles offer proactive approach to prevention and problem-solving

Since inception, huddle participation generally averages about 10-15 representatives from PSO member organizations. As participation grew, affinity groups were launched to better meet the patient safety challenges that are unique to different types of PSO members.

In early 2018, affinity huddles were added for academic medical centers, physician groups/ambulatory facilities and behavioral health organizations, bringing the total number of huddles to four. The academic medical center and the general PSO huddles meet bi-monthly, with the physician group/ambulatory facilities meeting monthly. The newest affinity huddle for behavioral health facilities meets twice annually.

The 30-minute calls are free-flowing conversations where the participants drive the topics discussed. “Participants share information about an issue or event, and someone else inevitably says, ‘Oh, I’ve dealt with that exact issue, and I have a great solution plan that I’ve developed for it, which I’ll be glad to share,’ ” said Flynn. “We send the learnings out to everyone in that affinity group, and if we think it’s applicable, we’ll even send it to the other affinity groups, as well.”

One huddle participant said, “I was able to complete a gap analysis from the policies shared after the huddle and improve current practices at my organization.” Another noted, “I find the huddles very helpful, especially knowing that other organizations share the same struggles.”

Safe tables in the growing PSO

While the huddles are one way to learn and share information, safe tables offer another, more structured approach. Happening up to six times a year, safe table topics are based on review of event data submitted by PSO members for the preceding 12 months. Safe tables, which like huddles are conducted by conference call, are also specific to affinity group. Topics in 2017 included medication safety, patient falls, care coordination, electronic communication and burns in the operating room. The 2018 line-up currently includes managing telemetry, behavioral issues, opioids and diagnostic errors. 

Flynn explained that safe tables aren’t just discussions about past events or on-the-spot problem-solving with members.

“We also try to identify why events are occurring and then bring that information back to an expert advisory team to help design leading practices as a result of learning from the safe table,” said Flynn. “For example, during last year’s safe table discussion about DOACs, we heard that members thought nurses could not use the override feature to obtain DOACs prior to pharmacy review. And, if it was happening, members thought it could only be happening in critical access hospitals. However, we identified that these events were happening in hospitals other than critical access hospitals. So, our alert needed to contain recommendations related to DOACs and pharmacy overrides.”

While the PSO generally bases safe table topics on its review of high-harm data over the last year, they are also flexible to include emergent topics that are causing widespread incidents of patient harm. 

“Light source cords, which attach to certain endoscopes, can cause patient burns if accidentally set on or near the patient or if the cord falls off the scope during a procedure. We learned of incidents that had occurred where light source cords had fallen off during procedures,” said Flynn. “We quickly convened members and the manufacturer to discuss the issue. We also created an alert with recommendations for preventing burns from light source cords in operative procedures. We have to stay responsive, whether it’s through huddles or a safe tables to respond quickly as situations arise.”

Membership within the Vizient PSO grew in 2017 to 266 participating organizations, up from 217 the year prior. Flynn said she and her staff are working to inform as many patient safety managers as possible about the PSO, huddles and safe tables. Flynn said she hopes participation in the huddles and safe tables will continue to grow in number.

For more information on how the Vizient PSO strives to achieve patient safety or to learn how to join the Vizient PSO, click here.

Published: March 13, 2018