Improving Reporting Culture through Daily Safety Huddle

The Institute of Medicine’s report “To Err is Human” remains relevant two decades later: medical error is the fourth leading cause of death in the United States and 40% of hospitalized children experience medical error. One obstacle to safer care is lack of error reporting. That omission denies the opportunity to learn from those events. Safety Culture describes a work environment conducive to reporting, and its properties are measurable using the Safety of Patients Survey (SOPS 1.0 TM). On a pediatric acute care unit in a children’s hospital in southeastern U. S., SOPS 1.0TM scores and error reporting fell well below agency benchmarks. The purpose of this quality improvement project was to improve error reporting and SOPS 1.0TM scores specific to reporting through a Safety Huddle Intervention. Marshall Ganz’s Change through Public Narrative Framework provided the theoretical design for this project: a story of self, a story of us, a story of now. The SOPS 1.0 TM was implemented before and after the six-week intervention on the project unit and a comparison unit and monthly error reporting was tracked before and after the intervention on those same units. The 5 composites of SOPS 1.0 TM purported to measure reporting culture showed no statistically significant differences after the intervention, or between the project and comparison units. Error reporting increased after the intervention on the project unit (p=0.0121) but not the comparison unit. Of note, this quality improvement project took place during the COVid 19 pandemic, and survey results revealed a preoccupation with staffing as an overriding concern for patient safety.