POST-EVENT SAFETY HUDDLES

INFORMATION FOR CLINICIANS & HEALTH PROFESSIONALS

A post-event Safety Huddle is a multidisciplinary Including patients and their family or carers
team review which takes place as soon as possible Where appropriate, include the patient and their
after a safety incident or a near miss is detected family and carers as part of the review team.
(ideally before the end of the shift, while the event Multiple perspectives exploring why an incident
is still fresh in people's minds). occurred helps teams to understand the factors
contributing to the incident. It also promotes a
Post-event Safety Huddles happen after immediate partnership model in developing a sustainable risk
care has been provided to the effected individual mitigation plan.
and can occur following incidents and events such
as: Answers needed from post-event Safety
 A patient fall Huddles
 A medication error  What was planned?
 Patient complaint  What happened?
 Threats to staff safety  What are the gaps?
 Equipment failure  Who was affected?
 Concerning trends arising in IIMS  What did we do to reduce the risk?
 How do you know the risk was reduced?
Purpose of post-event Safety Huddles  Who is accountable for any raised actions?
Post-event Safety Huddles:  Who is responsible for the documentation?
 Uncover the contributing factors leading to the  Have we met the needs of the affected patient
safety event. or staff member?
 Allow staff to quickly develop plans to prevent a  What can we learn?
reoccurrence and prevent future harm to
patients, families and staff. Always start with an introduction to ensure all
 Identify whether the harm or harm risk was participants understand the purpose and process.
related to patient factors, or systems and
processes. The focus is always on processes and not people as
 Provide reassurance that something is being safety events are usually symptoms of a larger
done. problem.
 Enhance teamwork and communication
ensuring everyone is on the same page.
About Team Culture and Communication
The CEC's Team Culture and Communication aims to enhance
What do Post-Event Safety Huddles look like? teamwork and communication at the point of care and support
Post-event Safety Huddles are a safe space clinicians to create the conditions to allow quality and safety
encouraging open and honest conversation. They improvement to occur.
are an opportunity to accept responsibility and
For further information, please visit
learn from errors, and are facilitated by a team
http://www.cec.health.nsw.gov.au
leader, such as the nurse in-charge, an experienced
clinician, or the Unit Manager. Program Lead Team Effectiveness
CEC-TeamEffectiveness@health.nsw.gov.au
Post-Event Safety Huddles Information for Clinicians and Health Professionals 02 92695615
Released October 2017 © Clinical Excellence Commission. SHPN (CEC) 170543