Overview
Summary
Post notification of a significant clinical incident or adverse event, a multidisciplinary team meet to review the patient care, identify contributing factors and put in place appropriate mitigation strategies.
Dates: October 2025 - ongoing
Implementation sites: Gold Coast University Hospital
Aim
The aim of this project was to strengthen patient safety process across the organisation.
Outcomes
This improvement strategy is designed to:
- focus on immediate actions to mitigate emerging risks
- expediate escalation and resolution of safety concerns
- build psychological safety, accountability and real time responsiveness
- raise situational awareness
- strengthen communication and a culture of safety
- determine the severity of the incident with a proposed review methodology
- provide assurance that something is being done.
Background
Prior to the implementation of the Post Event Safety Huddle (PESH), a weekly Executive Triage Meeting was held to review all unconfirmed SAC 1 significant/serious clinical incidents. It was recognised this approach did not allow for the required divisional and professional leads specific to the case to be at the discussion due to the batching of clinical incidents being discussed.
The Gold Coast Health PESH process was adapted from the Clinical Excellence Commission Post Event Safety Huddle model. It was developed in June 2025 and piloted in a small number of clinical areas including the emergency department. During this time, the exiting process of the Executive Triage Meeting continued to occur for all other clinical areas. This dual approach enabled real-time testing and refinement before being widely implemented. In October 2025, the PESH was implemented throughout the organisation. The intent was to enhance early incident response in consultation with the appropriate stakeholders aligned to the clinical incident/serious event, with a timelier approach to review.
To support documentation of the PESH, the Immediate Response Checklist and Action Plan (IRCAP) was developed. The outcomes of the PESH are recorded in the Patient Safety Activity Register which is currently being migrated to RedCap.
Methods
The PESH is designed to occur rapidly following notification of a significant/serious clinical incident. It occurs within 72 hours of notification of the event and requires the assembly of a defined multidisciplinary leadership group.
It is designed to:
- identify contributing factors and to put in place the appropriate mitigation strategies,
- confirm the SAC rating,
- confirm that clinician disclosure has occurred,
- outline the immediate actions and
- assess staff wellbeing.
Discussion
Implementation Data:
- Since commencement of the project to 31st January 2026, 73 Patient Safety Event Huddles have occurred. This has resulted in 210 actions with 109 of these completed.
Essential to this project’s success has been:
- Executive Leadership: to develop and reinforce the vision and support staff through the change process.
- Defining Preparation Requirements: to ensure effective use of the 30-minute huddle, defining the preparation requirements has assisted to ensure a structured and comprehensive review and discussion can occur
- Development of a supporting documentation tool: the Immediate Response Checklist and Action Plan (IRCAP) supports a structured and consistent approach to presenting the clinical incident.
- Development of a Patient Safety Activity Register: to record and monitor the clinical incidents discussed at the PESH and record and monitor any associated actions.
Lessons Learnt / Limitations:
- There are recognised challenges for the requested attendees to be available and prepared for the PESH at short notice (including balancing clinical workloads, meetings and other urgent priorities). By establishing an agreed shared vision and commitment across the leadership teams to improve patient safety outcomes, this has not proven to be a barrier to the success of the PESH. Ongoing evaluation of the improvement strategy will continue to occur.
Applicability across Queensland Health
- The PESH would be suitable to apply in all Hospital and Health Services across Queensland.
Next Steps
- Formal evaluation of the project will occur at 12 months from commencement (October 2026).
.
References
Safety Huddle Implementation Guide, 2017, Clinical Excellence Commission Safety Huddles Implementation Guide
Key contact
Melissa Hortz
Acting Patient Safety and Quality Improvement Lead
Gold Coast University Hospital