Journal Article

Medication event huddles: a tool for reducing adverse drug events.

Morvay S, Lewe D, Stewart B, et al. Joint Commission journal on quality and patient safety. 2014;40:39-45.

Retrospective analysis of adverse events is traditionally performed using tools such as root cause analysis. These methods are limited if—as is often the case—the analysis is performed weeks to months after the incident, since those involved may not recall the events surrounding the error accurately. This article describes how a children's hospital implemented medication event huddles as a way of analyzing adverse drug events contemporaneously. Huddles, which included nursing and pharmacy leadership along with the unit's frontline staff, took place immediately after any clinical adverse drug event and used a formal protocol to identify active and latent errors leading to the incident. The huddles were viewed as useful and nonpunitive by frontline staff and management and led to several system improvements. Prior studies have discussed how huddles may be used to enhance situational awareness and detect other latent safety threats.