Reducing hospital-acquired pressure ulcers through focused clinical daily safety huddles in a stroke unit

Patient safety remains a critical concern in healthcare systems worldwide, particularly in acute settings such as stroke units, where multidisciplinary co-ordination is essential.

This study explores the implementation and impact of a focused clinical daily safety huddle (FCDSH) as a non-technical intervention aimed at enhancing patient safety, reducing hospital-acquired pressure ulcers (HAPUs), and improving interprofessional collaboration. The project employed Kotter's eight-step change model to guide the implementation process and used Plan-Do-Study-Act (PDSA) cycles for iterative development. Stakeholder engagement, coaching leadership methodology, and a robust data collection process, including run charts, supported the intervention.

The results demonstrated a significant increase in the number of days between reported pressure ulcers, with the ward achieving 142 days without an incident post intervention compared with a baseline average of 18.2 days. The findings highlight the effectiveness of FCDSHs in improving communication, fostering teamwork, and reducing preventable patient harm.

This service evaluation contributes to the growing evidence base for human factors approaches and non-technical skills in clinical practice.