• Led by Leeds Teaching Hospitals NHS Trust in collaboration with the Yorkshire and Humber Improvement Academy.
  • Involved the scaling up of ‘patient safety huddles’ in 136 inpatient wards across three acute NHS trusts (five hospitals) in Yorkshire and Humber.
  • Patient safety huddles are daily, focused frontline team discussions of specific patient harms, supported by improvement skills, coaching, data visualisation and feedback.

Estimates suggest that approximately 5–10% of hospitalised patients in high-income countries experience harm, and about one third of these harmful events are preventable.

The local, national and international patient safety initiatives that have been designed over the last decade have almost all failed to demonstrate significant impact. Reducing harm across a hospital requires behaviour and cultural change at a ward team level.

Leeds Teaching Hospitals NHS Trust developed and piloted patient safety huddles (PSHs) to help reduce patient harm. The PSHs are led by the most appropriate clinician (for example a doctor, nurse or allied health professional) and take place at a regular time each day, for 5–15 minutes. They provide a non-judgemental, no-fear space, where team members (including non-clinical staff) develop the confidence to speak up and jointly act on any safety concerns they have.

The pilot of the PSHs demonstrated a reduction in the number of falls, an increase in overall staff morale and improved teamwork.

This project involved supporting all adult inpatient wards to embed PSHs in Leeds Teaching Hospitals NHS Trust, Barnsley Hospital NHS Foundation Trust and York Teaching Hospital NHS Foundation Trust.

By the end of the project, evaluation showed that over 70% of wards in the five hospitals successfully embedded PSHs. This number continued to rise after the end of the project due to developing sustainability plans. The PSHs generally had positive feedback from frontline staff, and were found to enhance team working and safety culture.

The pooled hospital results showed that there was a significant reduction in the rate of falls after the introduction of PSHs. The return on investment from wards addressing harms associated with reducing falls was over 100%.

Contact information

  • Dr Alison Cracknell, Consultant in Medicine for Older People, Leeds Teaching Hospitals NHS Trust
  • Alison Lovatt, Director of Nursing, Yorkshire and Humber Improvement Academy
  • Vicky Padgett, Project Manager, Yorkshire and Humber Improvement Academy

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Scaling Up Improvement

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