How Handoffs Can Kill

Hospitals combat errors at the ‘hand-off’

I’ve blogged before about how handoffs in a process create opportunities for errors. I wrote about a trivial situation where I got the wrong muffin and Seth Godin wrote about getting the right breakfast because there were fewer handoffs.

Now, the article linked above focuses on standardizing handoffs in hospital settings. In an effort to reduce errors, many hospitals have shortened doctor and nurse shifts, to prevent errors that are caused by fatigue. The unintended consequence is that you now have more patient handoffs… and communication is more critical than with a bran muffin.

Here is the standard method that some hospitals are adopting, borrowed from nuclear sub practices (and more proof that you CAN learn from other industries):

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“The SBAR checklist some hospitals are using to improve patient hand-offs:

  • S: Describe the Situation. In a few seconds, get someone’s attention.
  • B: Background. Provide enough information to give the listener some context for the problem.
  • A: Assessment. Give your assessment of the overall condition
  • R: Recommendation. Give your specific recommendations.”

It’s a great opportunity, as we return to work Wednesday, to think about the handoffs in our own processes. Can we standardize communication from shift to shift or person to person in a process? How can we simplify our work to reduce the opportunities for errors? How can we use communication to encourage teamwork and get people to speak up?

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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an book titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

1 Comment

  1. Chet Frame says

    Isn’t that why many of us plan a trip using only one airline? It is so much simpler and the results are usually better if we are only dealing with one airline company. I just returned from a trip over eleven days with five different airlines and ten time zones, and I had my suitcase for a day and a half out of all that time due to a hand off issue that crossed airline issues and international boundaries. Not to mention, but I will, the pain of having to wait at baggage claim after almost every leg (maybe I should have claimed it after every leg)because of changing airlines and terminals and they can’t or won’t take care of it for you.

    I also spent more than eight hours in “Wait” as air traffic controllers tried to make sense of hundreds of airplanes moving around storms and across runways, etc. I was still able to travel in hours what it took my ancestors months to complete. We have come a long way, but there is so much more that we could do.

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