The Effect of a System-Level Tiered Huddle System on Reporting Patient Safety Events: An Interrupted Time Series Analysis

Published:August 17, 2022DOI:


      The objective of this research was to evaluate the effect of implementing a system-level tiered huddle system (THS) on the reporting of patient safety events into the official event reporting system.


      A quasi-experimental study using interrupted time series was conducted to assess the impact and changes to trends in the reporting of patient safety events pre- (February–July 2020; six months) and post- (September 2020–February 2021; six months) THS implementation within one health care system (238 clinics and 4 hospitals). The severity of harm was analyzed in July 2021 using a modified Agency for Healthcare Research and Quality (AHRQ) harm score classification. The primary outcome measure was the number of patient safety events reported per month. Secondary outcomes included the number of patient safety events reported per month by each AHRQ harm score classification.


      The system-level THS implementation led to a significant and immediate increase in the total number of patient safety events reported per month (777.73, 95% confidence interval [CI] 310.78–1,244.68, p = 0.004). Similar significant increases were seen for reported numbers of unsafe conditions, near misses, no-harm events that reached patients, and temporary harm (p < 0.05 for each). Reporting of events with permanent harm and deaths also increased but was not statistically significant, likely due to the small number of reported events involving actual harm.


      These findings suggest that system-level THS implementation may increase reporting of patient safety events in the official event reporting system.
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