Decreasing Adverse Events through Night Talks: An Interdisciplinary, Hospital-Based Quality Improvement Project

Perm J. Fall 2009;13(4):16-22. doi: 10.7812/tpp/09-076.


Background: The majority of medical adverse events are secondary to errors in communication. The Joint Commission (known until 2007 as the Joint Commission on the Accreditation of Healthcare Organizations) reports that 70% of sentinel events are the result of communication failures. Review of nonperioperative adverse events at Cincinnati Children's Hospital Medical Center in 2007 found similar statistics: 57% were related to failure to recognize abnormal vital signs and to communicate or address parents' or nurses' concerns.

Objective: To increase by 80% the number of days between near misses in pediatric neurosurgical patients because of failure to address abnormal vital signs or parents' or nurses' concerns during the night shift.

Materials and methods: Baseline data on near misses from the previous night were collected with the use of a written questionnaire completed the next morning by the interns, patient-care facilitators or charge nurse, and attending physicians. Laminated cards with three standardized questions were created to guide a late-evening review of patients' status by residents, attending physicians, and nurses: the Night Talks discussion. After initiation of Night Talks, data were collected for issues addressed by Night Talks as well as for preventable adverse events.

Main outcome measure: Number of days between near misses.

Results: During a two-month period before the introduction of Night Talks, there was an average of 3.8 days between near misses on neurosurgery patients. After the initiation of Night Talks, days between near misses due to the failure to address abnormal vital signs or parents' or nurses' concerns increased to 201 days, a 5360% change.

Conclusion: Instituting standardized Night Talks substantially reduced near misses in neurosurgical patients at our institution at night.