Safety Huddles in a Culture of Patient Safety

Originally published in Patient Safety & Quality Healthcare magazine

By Mary Lu Gerke, PhD, RN; Cheryl Uffelman, RN, MSN;
Kim Weber Chandler, RN, BSN

When the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System in 2000, the executives and health quality and patient safety staff at Gundersen Lutheran immediately started discussions around issues emphasized in the report. One of the initiatives started at that time included increasing the engagement of our frontline staff in improving patient safety. This foundational work supported the development and evolution of what we now call Safety Huddles.


Gundersen Lutheran provides high-quality emergency, specialty, and primary healthcare services to patients throughout western Wisconsin, southeastern Minnesota, and northeastern Iowa. As one of the largest multispecialty group medical practices and a major teaching hospital, the organization comprises nearly 700 medical, dental, and associate staff, supported by a staff of more than 6,000.

Safety Huddles at the hospital officially began in July 2006. One of our first formal Safety Huddles was prompted by a tragic event that occurred in a major healthcare facility in Wisconsin. A 15-year-old first-time mom received an epidural medication intravenously, which led to a seizure and, subsequently, her death. When we heard this story in the news, many of us wondered if something similar could happen at our hospital. The quality and patient safety staff took the lead in pulling together a group of professionals and frontline staff to explore that possibility. 

Members of the group included the patient safety coordinator, medication safety manager, OB and pediatric pharmacists, director of pharmacy, managers of labor and delivery, registered nurses from labor and delivery, anesthesiologists, and risk management staff. This meeting was called a Safety Huddle because the group “huddled” to find out what issues led to the patient’s death, what could be done to fix them, and assure itself that a similar incident would not happen here.

Prior to the Safety Huddle, the patient safety coordinator read the details of the incident and put together a list of system failures at that hospital that might have led to the event. The coordinator also interviewed bedside RNs from Gundersen Lutheran’s labor and delivery to determine and list potential failures. That list was provided to the group at the beginning of the Safety Huddle.

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