NHS England: Swarm huddle (August 2022)

Summary

A swarm is designed to start as soon as possible after a patient safety incident occurs. Healthcare organisations in the US1 and UK2 have used swarm-based huddles to identify learning from patient safety incidents. Immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning.

They can prevent:

• those affected forgetting key information because there is a time delay before their perspective on what happened is sought
• fear, gossip and blame; by providing an opportunity to remind those involved that the aim following an incident is learning and improvement
• information about what happened and ‘work as done’ being lost because those affected leave the organisation where the incident occurred.

This swarm tool provided by NHS England integrates the SEIPS3 framework and swarm approach to explore in a post-incident huddle what happened and how it happened in the context of how care was being delivered in the real world (ie work as done).