Lea Anne Gardner, PhD, RN
Senior Patient Safety Analyst
Pennsylvania Patient Safety Authority

Abstract

Handoffs are an integral part of care coordination and the delivery of safe patient care. Effective handoffs have multiple functions: transferring responsibility and accountability for the patient’s care and confirming the accuracy of information from one healthcare worker to another and providing opportunities to catch and correct errors. In Pennsylvania, facilities reported 1,565 handoff-related events through the Pennsylvania Patient Safety Reporting System (PA-PSRS) that occurred in 2014 and 2015. About 60% of the handoff reports indicated discrepancies between information shared and the patient’s condition noted during or after a handoff with no description of a follow up; in 40% of the event reports, a follow up in patient care to address the discrepancy was stated. In addition, about 20% of the event reports stated that there was no handoff given and in another 16% of the event reports, details about the patient’s condition were omitted from the handoff. Using handoff processes that incorporate critical thinking and reasoning skills to address patient needs, addressing environmental distractions and communication deficits, and providing handoff training and education are strategies to improve patient handoff communications.

Introduction

Personnel at a Pennsylvania healthcare facility contacted the Pennsylvania Patient Safety Authority to learn about the types of handoff-related events reported by other facilities in the state so they could adapt and improve their handoff processes. Handoffs involve sharing patient information and often include performing a visual inspection of the patient to confirm the accuracy of information conveyed.¹ Handoff communications coordinate patient care by passing essential information about a patient’s health status and responsibility for the patient’s care from one healthcare worker to another. They occur at change of shift (e.g., attending physicians, nursing staff), transfer of patients from one area within a healthcare facility to another, transfers between facilities, and during shifts when staff leave the unit or area to tend to other patients or take a break. Each handoff provides opportunities to catch and correct errors.²

When a handoff is successfully completed, the next person responsible for the patient has the necessary information to inform care for that specific patient. In cases in which information is incomplete or a handoff fails to occur, an incomplete understanding of a patient’s condition may contribute to inappropriate or inadequate treatment. In a study by Tucker and Edmondson, missing or incorrect information was one of five broad types of healthcare problems or process failures encountered by nurses.³ Lapses in handoffs impact all groups of healthcare clinicians (e.g., physicians, nurses, allied health professionals) and nonclinicians (e.g., transportation staff).

Handoffs between healthcare workers occur hundreds to thousands of times each day, creating opportunities to identify effective handoff communications. The Joint Commission identified [inadequate] communication as the third most frequently identified root cause for a sentinel event in 2014 and 2015.⁴ Good communication is a part of patient care and leadership standards.^5-7 The challenge in completing a successful handoff is knowing what information is most important and how to convey the information in a clear and concise manner appropriate for the patient’s circumstances. For example, hospital intensive care units may adhere to handoff criteria that differ from obstetric unit criteria. Effective handoffs require teamwork, shared practices, and shared expectations (e.g., use of handoff tools).^8-10

The literature is replete with articles focusing on the use of handoff tools.^10-15 Healthcare professionals have developed and validated a variety of handoff tools that provide a shared mental model to help complete a patient handoff. Examples of some well-known handoff tools for clinicians include SBAR (Situation, Background, Assessment, and Response) and I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver), and for clinical and nonclinical staff, the “ticket to ride” tool, used when transporting patients.^15-18  

Handoff tools help clinicians gather needed information and pass it on to other healthcare workers, but this integral part of coordinating patient care can fail.^2,14,19-23 (See Table 1.)

Methods

Analysts queried the PA-PSRS database to identify handoff-related events reported by Pennsylvania healthcare facilities that occurred in 2014 and 2015. The query searched free-text data fields of the event type “Other,” event description, and recommendations using the following keywords: handover, sign off, nursing report, shift report, off shift, in shift, inshift, hand off, handoff, sign out, signout, cover, and to cover. The initial query resulted in 3,566 event reports. Analysts reviewed the event reports and excluded 2,001 with no mention of a handoff or only a cursory mention (e.g., a statement of intent to provide patient information at a future handoff). Analysts then applied the following criteria when reviewing and identifying handoff event reports: the setting in which the handoff occurred or should have occurred (e.g., shift reports or unit transfers); discrepancies such as omitted or inconsistent information; lack of physical checks of equipment, orders, or medications; healthcare clinicians involved in the handoff; and statements of no handoff performed.

Results

Of the 1,565 handoff-related event reports, 99.1% (n = 1,551) were reported as Incidents (e.g., near-miss events or events that reached the patient but did not cause harm). The remaining 0.9% (n = 14) were reported as Serious Events (i.e., an event that reached the patient that contributed to or resulted in harm).

Handoff Settings and Staff Involvement

Three handoff settings were identified in the event descriptions:

• Shift-to-shift transitions (39%, n = 610 of 1,565)
• Unit-to-unit transfers (30.3%, n = 474)
• Temporary coverage (e.g., during a lunch break; 1.8%, n = 28)

In the final 28.9% (n = 453), the handoff setting was unidentified.

Specific healthcare professionals were identified in the majority of the event reports (68.6%, n = 1,074 of 1,565). In many cases, more than one class of healthcare professional was identified in the event description, but their role as the giver or receiver in the handoff was not consistently stated. They are grouped as follows:

• Registered nurse (86.4%, n = 928 of 1,074)
• Medical doctor (18.2%, n = 195)
• Allied health professional (6.2%, n = 67)
• Nonclinical staff (2%, n = 22)
• Student nurse or resident (2%, n = 21)

Completed Handoffs

The majority of the event reports identified the occurrence of a handoff, 81% (n = 1,268 of 1,565), versus events reporting lack of a handoff (see Figure). Discrepancies between the information shared and the patient’s condition was the most common problem. Event reports that identified a discrepancy without stating whether the staff addressed the discrepancy accounted for 59.2% (n = 751 of 1,268) of these reports; in the remaining 40.8% (n = 517) of the handoff reports, staff identified and followed up on handoff discrepancies. Discrepancies without an identified follow-up were found most often after a handoff occurred, 56.3% (n = 423 of 751), and included omitted information in 61.5% (n = 260 of 423) and a lack of a physical check or failure to clarify intravenous (IV) lines, orders, or skin conditions during a handoff in 10.2% (n = 43 of 423) of events.

Good Follow Through

The following narratives illustrate efforts to see patient issues through to completion:*

Charge registered nurse (RN) received call from the lab with a critical lab value. Patient was not on the unit and no hand-off report was yet given on the patient. The patient was [still] showing to be [on another unit]. The RN [who received the critical lab value] called the other unit to make [sure that the] patient’s RN was aware [of the lab value]. Staff stated that the patient had left the unit and was possibly having a procedure. The charge RN called the [procedure room], reached the RN caring for the patient, and passed on these critical lab results.

During change of shift report, the outgoing RN reported that new skin breakdown on the patient’s buttock was present. The outgoing RN stated the wound was not there when he cared for the patient previously. The oncoming RN’s assessment of the wound noted several areas of open skin. The patient was incontinent and requires frequent care. Barrier creams were applied to the skin. The certified registered nurse practitioner was informed of [the patient’s] skin integrity and the certified wound ostomy and continence nurse saw patient the next day.

Discrepancies Noted During Handoff without Indication of Staff Follow Through (n = 136 of 751)

Medication errors comprised more than half of the 136 events in which discrepancies were noted during the handoff (55.1%, n = 75) and included dose omission, extra or wrong dose, prescription delays, monitoring errors, and incorrect medication lists. The PA-PSRS miscellaneous or “Other” category comprised 17.6% (n = 24) of event reports; catheter-line problems (e.g., infusion rates, infiltrates) and patient identification issues accounted for the majority of these event reports. Errors in procedures, tests, or treatments included problems such as delays in providing treatments or receiving test results, missed treatments, or dietary issues and accounted for 14.0% (n = 19) of these event reports. The remaining event reports involved transfusions, skin integrity, equipment problems, and complications of procedures, tests, or treatments.

While giving handoff report in the OR, the [outgoing] nurse noted an error on the consent. The consent [had the wrong procedure written]. Prior to leaving the preoperative area, the patient had verified with the OR staff what procedure he was having performed. The typo on the consent went unnoticed at that time.

Discrepancies Noted After Handoff without Indication of Staff Follow Through (n = 120 of 423)

Medication errors and errors in procedures, tests, and treatments comprised the majority of the 120 event reports in which discrepancies were noted after the handoff (41.7%, n = 50 and 33.3%, n = 40, respectively). Reasons for medication errors were similar to the discrepancies noted during handoff, such as dose omission, wrong dose, and extra dose. Errors in procedures, tests, and treatments included problems related to test orders, scheduling, lost specimens, and missing results. The remaining events included equipment problems, skin integrity problems, transfusions, and problems with IV lines, monitoring, transfers, and documentation issues.

Patient taken to the OR for [a procedure]. Later, the OR called and told the nurse that surgery was cancelled due to [a critical lab value]. The OR told the nurse to come and get the patient, because the patient was [sedated]. When the nurse [arrived] to the OR, the patient was on the stretcher, struggling to breathe. The RN brought the patient back to the floor and applied [oxygen]. Better communication is needed between units.

The RN was leaving the building at [night]. The technician reports a patient has been in the waiting area for several hours to have a test performed. The patient states he arrived [in the early afternoon] and did not get a [gown or ID band] when he checked in. A different RN who gave a handoff [to the outgoing RN] at [the end of day] stated the schedule was done. The [outgoing] RN was not notified of the patient waiting [until she was leaving].

No Physical Check of Equipment, Orders, or Medications without Indication of Staff Follow Through (n = 43 of 423)

Medication errors accounted for 79.1% (n = 34 of 43) of events in which physical checks were not performed. The nine remaining events without physical checks involved pressure ulcers, blisters, IV infiltrations, laboratory delays, falls, and equipment and discharge issues.

The patient was ordered to be transferred to the unit. The RN received report [prior to patient arrival]. The patient was apparently brought to the unit from the OR. No one from the OR [informed any staff on unit] that they brought the patient [to the unit]. Apparently, the patient was hooked up to the monitor. The charge nurse noted [a while later] that a patient was on the monitor. The [charge] RN went to the room to check to see why the monitor would [have a reading] and found the patient in bed.

The nurse found the [medication] infusion ordered at 17 units/hour was turned off. [The nurse was] unable to determine how long the IV was off. Line tracing was not completed at handoff.

When the RN went to give the dose of [medication], he found a syringe from the previous dose full and never infused. Nursing failed to check line during handoff at shift change.

Detail Not Mentioned during Handoff without Indication of Staff Follow Through (n = 260 of 423)

Two-hundred and sixty reports cited information omitted during handoff. The most frequent event type in this group was medication errors (33.5%, n = 87). Errors in procedures, tests, or treatments (e.g., delays or omissions in treatments) accounted for 27.7% (n = 72) of event reports with missing information; miscellaneous type reports (e.g., documentation issues) accounted for 17.3%, (n = 45) of these reports. The remaining reports about missing information were categorized as complications of procedures, tests, or treatments; equipment problems; skin-related problems; transfusions; and falls.

The RN transported the patient via bed and left prior to bedside handoff. The patient’s do not resuscitate (DNR) status was not communicated during the phone report. The patient arrived complaining of shortness of breath. [The patient’s condition deteriorated]; the patient became unresponsive and stopped breathing. A code blue was called. On hearing the code paged overhead, the RN from the [unit that the patient transferred from] arrived and informed [the staff of the patient’s] DNR status.

The doctor found a 10-second pause on the telemetry monitor [strip] in the patient’s chart. The RN from the prior shift never informed anyone, including the doctor [on call or RN during handoff].

The patient was brought to the [procedural area] from the unit. Upon arrival, a ticket to ride [slip] in the chart was checked for the patient assessment and isolation needs. Isolation was listed as none. The patient was in the procedural area for [more than four hours] in multiple rooms. During transportation [back to her room] the patient [questioned] why [the staff] did not wear isolation gowns for her exam due to her being on contact precautions.

No Handoffs

While the majority of handoff-related event reports indicated the presence of a handoff, the lack of a handoff was noted in 19.0% (n = 297 of 1,565) of the event reports.

A pharmacy technician delivered a controlled substance directly to the patient’s room and had the patient’s family member “sign off” for [the medication]. When the staff went into the room several minutes later, the family member handed the staff person the medication and said, “I think this might be for you.”

The patient arrived to the room. No handoff was placed in the electronic record; no verbal report was called. No notification that the patient was coming to the floor.

Transport brought the patient back to the floor and provided no communication to the [nursing staff]. The patient was without respirations and [a code blue was called]. Follow-up: discussed the importance of proper handoff communication process with transporter… and staff.

Nurse left the unit with her patient without telling any staff where she was going. After she returned, the [nurse who left] was told she needed to report off to someone [since the floor staff] didn’t know anything about her other patients or where she had gone.

_______________

* The details of the PA-PSRS event narratives in this article have been modified to preserve confidentiality.

Discussion

Although a lack of accurate and complete information received during a handoff can have disastrous consequences for patients, in 40.8% of the event reports that stated a handoff occurred, staff followed up on important patient information. Much can be learned about ways to enhance patient safety, even when care is delivered as expected without harm.

Safety-II

Safety-I is usually associated with things that go wrong.²⁴ The concept of Safety-II focuses on things that go right in healthcare.^24,25 When actions occur regularly and produce intended or expected results, people pay less attention because things work as expected.²⁴ This behavior of not paying attention to things that go right is referred to as habituation.²⁴ Habits are viewed as common, certain, and expected actions that need no extraneous help.²⁴

However, Hollnagel provides an explanation of Safety-II that challenges behaviors such as habituation. According to Hollnagel, “Safety-II explicitly assumes that systems work because people are able to adjust what they do to match the conditions of their work. In this scenario, people learn to adjust to their work environment to complete the expected tasks.”²⁴ Studying handoff processes that deliver generally complete and accurate information may reveal ways that staff adjust to work conditions that can be used to improve handoff processes.

A Systems Perspective

A systems perspective focuses on understanding and examining connections and interactions between individual components (e.g., handoff processes) that make up a system.^26,27 Rather than focusing on single components as causal factors in accidents, systems theory considers the interactions of multiple components.²⁸ In healthcare, internal and external organizational factors make up a diverse group of components that influence system functioning.*

Using a systems approach to evaluate and address the problem of incomplete or missing handoffs can provide insight into the organizational factors that influence the process of sharing information between people. Managing the many diverse organizational factors involves individual decision making when determining what information to include and present at a handoff. Leveson posits that each individual decision may appear safe and rational within the context of the individual’s work environment and local pressures but may be unsafe when considering larger system influences.²⁸ She states that “it is difficult if not impossible for any individual to judge the safety of their decisions when it is dependent on the decisions made by other people in other departments and organizations.”²⁸ For example, individuals can vary greatly in deciding what information to share during a handoff. It may be possible to structure handoff processes to help healthcare staff to see the complete picture or implications of their actions.²⁹ Ongoing conversations between front-line staff and management using critical thinking and reasoning can help balance patient care delivery and determine how to modify strategies and activities to provide safe patient care (e.g., providing important information) while reducing the chance of errors.^27,29,30

Another enticing solution to reduce variations in handoff information is to standardize the handoff tool as part of the handoff process (see Challenges to Effective Standardization). Periodic evaluation of the solution (i.e., standardized handoff tool) is needed to confirm the resolution of problems. If the intervention does not achieve the intended results or achieves results for only a limited time, more fundamental interventions may be required.³¹ In systems theory, a quick or immediate solution to a problem that does not address the underlying cause is referred to as “shifting the burden.”³¹ Braun describes how an initial solution that provides symptomatic resolution “in the short run” may not address the underlying systemic problem(s) and can disrupt a worker’s ability to execute a prescribed task.³¹ For example, if something the worker needs is unavailable (e.g., patient information) or something is present that should not be, the task cannot be executed as planned.³¹

Risk Reduction Strategies

Table 2 lists strategies addressing many of the circumstances that can adversely affect handoffs; these strategies address individual and system barriers to effective communication. These risk reduction strategies align with the barriers to effective handoffs presented in Table 1. This list of strategies for effective handoffs is by no means exhaustive.

_______________

* Internal organizational factors refer to inside influences such as healthcare clinicians, allied health professionals, support staff, leadership, equipment, and organizational policies, procedures, and practices. External organizational factors refer to outside influences such as government rules, accreditation standards, laws, professional society recommendations, and influences from pharmaceutical and medical device manufacturers.

Limitations

PA-PSRS does not have a structured data field for handoffs; therefore, a keyword search of the event detail and other free text data fields was applied; facilities may have submitted reports using different terminology. Often event reports included limited information about the staff involved during the handoff, when the handoff occurred, and at what point in the handoff process a discrepancy was identified. Information about the circumstances present during a handoff is rarely mentioned, which restricts insights into why handoffs did not happen or why information was omitted. The event reports also do not contain information about how an outgoing staff member decided what information was important to communicate to the oncoming staff member.

Conclusion

In Pennsylvania, 40.8% of the completed handoff event reports exemplify how healthcare providers accomplish the intended purpose of a handoff, namely maintaining continuity of care, while addressing discrepancies that will inevitably arise when communicating patient information. These Safety-II events demonstrate the benefits of a good handoff, in which discrepancies are caught before harm reaches the patient. Using a systems approach that includes critical thinking skills coupled with the risk reduction strategies outlined in this article can help healthcare leadership and staff find ways to improve their facilities’ handoff processes.

Notes

1. Streeter AC. What nurses say: communication behaviors associated with the competent nursing handoff. University of Kentucky Doctoral Dissertations; 2010. Also available: http://uknowledge.uky.edu/gradschool_diss/66.
2. Cohen MD, Hilligoss PB. Handoffs in Hospitals: A review of the literature on information exchange while transferring patient responsibility or control. Ann Arbor (MI): School of Information, University of Michigan; 2009 Jan 16. Also available: https://deepblue.lib.umich.edu/handle/2027.42/61498.
3. Tucker AL, Edmondson AC. Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. Calif Manage Rev. 2003 Winter;45(2):55-72.
4. Sentinel event statistics released for 2014. [internet]. Joint Commission Online; 2015 Apr 29 [accessed 2016 Sep 26]. [2 p]. Available: http://www.jointcommission.org/assets/1/23/jconline_April_29_15.pdf.
5. Joint Commission Comprehensive Accreditation Manuals: Hospital. Washington (DC): The Joint Commission; 2016; Effective: 2016 Jul 1. Provision of care, treatment, and services. PC.02.02.01: The hospital coordinates the patient’s care, treatment, and services based on the patient’s needs.
6. Joint Commission Comprehensive Accreditation Manuals: Hospital. Washington (DC): The Joint Commission; 2016; Effective: 2016 Jul 1. Provision of care, treatment, and services. PC.02.01.21: The hospital effectively communicates with patients when providing care, treatment, and services.
7. Joint Commission Comprehensive Accreditation Manuals: Hospital. Washington (DC): The Joint Commission; 2016; Effective: 2016 Jul 1. Leadership. LD.03.04.01: The hospital communicates information related to safety and quality to those who need it, including staff, licensed independent practitioners, patients, families, and external interested parties.
8. Hunt CM. Patient safety is enhanced by teamwork. Pa Patient Saf Advis. 2010 Jun 16;7(Suppl 2):14-6. Also available: http://papatientsafety.pa.gov/ADVISORIES/Pages/2010sup2_14.aspx.
9. About TeamSTEPPS®. [internet]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2015 Aug [accessed 2016 Oct 06]. [6 p]. Available: http://www.ahrq.gov/teamstepps/about-teamstepps/index.html.
10. Deutsch ES, Binck B, Moore G, Karsh BT. S*T*A*R*T*: A great handoff - an approach to effective medical communication in a high-risk environment. In: Savage GT, Ford EW, editors. Patient Safety and Health Care Management. Vol. 7, United Kingdom: Emerald Group Publishing Limited; 2008. p. 241-258. (Advances in Health Care Management).
11. Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf. 2010 Feb;36(2):52-61. PMID: 20180437.
12. Strategies to improve handoffs. [internet]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Aug 4 [accessed 2016 Sep 21]. [2 p]. Available: https://innovations.ahrq.gov/qualitytools/strategies-improve-handoffs.
13. Abraham J, Kannampallil TG, Patel VL. Bridging gaps in handoffs: a continuity of care based approach. J Biomed Inform. 2012 Apr;45(2):240-54. Also available: http://dx.doi.org/10.1016/j.jbi.2011.10.011. PMID: 22094355.
14. Halm MA. Nursing handoffs: ensuring safe passage for patients. Am J Crit Care. 2013 Mar;22(2):158-62. Also available: http://dx.doi.org/10.4037/ajcc2013454. PMID: 23455866.
15. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, Noble EL, Tse LL, Dalal AK, Keohane CA, Lipsitz SR, Rothschild JM, Wien MF, Yoon CS, Zigmont KR, Wilson KM, O’Toole JK, Solan LG, Aylor M, Bismilla Z, Coffey M, Mahant S, Blankenburg RL, Destino LA, Everhart JL, Patel SJ, Bale JF, Spackman JB, Stevenson AT, Calaman S, Cole FS, Balmer DF, Hepps JH, Lopreiato JO, Yu CE, Sectish TC, Landrigan CP, I-PASS Study Group. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014 Nov 6;371(19):1803-12. Also available: http://dx.doi.org/10.1056/NEJMsa1405556. PMID: 25372088.
16. Why is SBAR communication so critical? [internet]. Centennial (CO): Safer Healthcare Partners, LLC; 2016 [accessed 2016 Oct 06]. [5 p]. Available: http://www.saferhealthcare.com/sbar/what-is-sbar/.
17. Pesanka DA, Greenhouse PK, Rack LL, Delucia GA, Perret RW, Scholle CC, Johnson MS, Janov CL. Ticket to ride: reducing handoff risk during hospital patient transport. J Nurs Care Qual. 2009 Apr-Jun;24(2):109-15. Also available: http://dx.doi.org/10.1097/01.NCQ.0000347446.98299.b5. PMID: 19287248.
18. Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC, I-PASS Study Group. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012 Feb;129(2):201-4. Also available: http://dx.doi.org/10.1542/peds.2011-2966. PMID: 22232313.
19. Riesenberg LA, Leitzsch J, Cunningham JM. Nursing handoffs: a systematic review of the literature. Am J Nurs. 2010 Apr;110(4):24-34; quiz 35-6. Also available: http://dx.doi.org/10.1097/01.NAJ.0000370154.79857.09. PMID: 20335686.
20. Friesen MA, White SV, Byers JF. Chapter 34: Handoffs: implications for nurses. In: Hughes RG, editor. Patient safety and quality: an evidence-based handbook for nurses. Rockville (MD): Agency of Healthcare Research and Quality (AHRQ); 2008. Also available: http://www.ncbi.nlm.nih.gov/books/NBK2649/.
21. Bright J, Long B. ED handoffs - the problem and what we can do to improve. [internet]. emDocs; 2015 Nov 18 [accessed 2016 Sep 21]. [8 p]. Available: http://www.emdocs.net/ed-handoffs-the-problem-and-what-we-can-do-to-improve/.
22. Gardner LA. Health literacy and patient safety events. Pa Patient Saf Advis. 2016 Jun 16;13(2):58-65. Also available: http://papatientsafety.pa.gov/ADVISORIES/Pages/201606_58.aspx.
23. VandenBerg AK. Patient hand offs: facilitating safe and effective transitions of care. Grand Rapids (MI): Kirkhoff College of Nursing, Grand Valley State University; 2013. 66 p. (Master’s Projects; Paper 1). Also available: http://scholarworks.gvsu.edu/cgi/viewcontent.cgi?article=1000&context=kcon_projects.
24. Hollnagel E. A tale of two safeties (draft). [internet]. 2012 [accessed 2016 Sep 26]. [13 p]. Available: http://www.erikhollnagel.com/A_tale_of_two_safeties.pdf.
25. Deutsch ES. “What goes wrong” (Safety-1) and “What goes right” (Safety-II). Pa Patient Saf Advis. 2015 Jun;12(2):83-4. Also available: http://papatientsafety.pa.gov/ADVISORIES/Pages/201506_83.aspx.
26. Basic principles of systems thinking as applied to management and leadership. [internet]. The Institute for Systemic Leadership; 2009 [accessed 2016 Sep 21]. [3 p]. Available: http://www.systemicleadershipinstitute.org/systemic-leadership/theories/basic-principles-of-systems-thinking-as-applied-to-management-and-leadership-2/.
27. Dolansky MA, Moore SM. Quality and Safety Education for Nurses (QSEN): The key is systems thinking. Online J Issues Nurs. 2013 Sep 30;18(3):Manuscript 1.
28. Leveson N. A new accident model for engineering safer systems. Saf Sci. 2004;42(4):237-70. Also available: http://sunnyday.mit.edu/accidents/safetyscience-single.pdf.
29. Rasmussen J. Risk management in a dynamic society: a modeling problem. Saf Sci. 1997;27(2-3):183-213.
30. Tucker AL, Edmondson AC. Why hospitals don’t learn from failures: organizational and psychological dynamics that inhabit system change. Calif Manage Rev. 2003 Winter;45(2):55-72.
31. Braun W. The Systems Modeling Workbook. 2002. The system archetypes. Also available: http://www.albany.edu/faculty/gpr/PAD724/724WebArticles/sys_archetypes.pdf. 

Supplemental Materials

Challenges to Effective Standardization

Applying a standard process to human behavior is intended to provide a consistent approach and a shared expectation of tasks between workers.¹ The challenge in standardizing a process, such as a handoff, is to be sure that the process does not turn into a one-size-fits-all approach. Training workers to think critically, using evidence-based information to make informed choices, and understanding what actions can be altered in a standardized process helps workers accomplish their job safely and effectively.^2,3 This is important because implementing a standard handoff process with a set of predictable steps has the potential to lead to repetitive behaviors that can turn into habits.² Over time, workers may disregard or take for granted information regularly shared in the handoff process to the point that attention is reduced and subtle but important information is missed or overlooked, potentially creating unsafe conditions.² Although standardizing processes and approaches to patient care can be beneficial, critical thinking and reasoning skills have an important place in patient care.

Notes

1. About TeamSTEPPS®. [internet]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2015 Aug [accessed 2016 Oct 06]. [6 p]. Available: http://www.ahrq.gov/teamstepps/about-teamstepps/index.html.
2. Hollnagel E. A tale of two safeties (draft). [internet]. 2012 [accessed 2016 Sep 26]. [13 p]. Available: http://www.erikhollnagel.com/A_tale_of_two_safeties.pdf.
3. Argyris C. Action science and organizational learning. J Manage Psych. 1995;10(6):20-6.