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):

“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?

Please check out my main blog page at

The RSS feed content you are reading is copyrighted by the author, Mark Graban.

, , , on the author's copyright.

What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.

Did you like this post? Make sure you don't miss a post or podcast — Subscribe to get notified about posts via email daily or weekly.

Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:

Get New Posts Sent To You

Select list(s):
Previous articleInnovation or Improvement?
Next articleThe Myth of Setting Goals
Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. 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.


Please enter your comment!
Please enter your name here

This site uses Akismet to reduce spam. Learn how your comment data is processed.