International Journal for Quality in Health Care 16:125-132 (2004)
International Journal for Quality in Health Care vol. 16 no. 2 © International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
Handoff strategies in settings with high consequences for failure: lessons for health care operations
1 Veteran’s Administration Getting at Patient Safety (GAPS) Center, Cincinnati, OH,
2 Roth Cognitive Engineering, Boston, MA,
3 Institute for Ergonomics, The Ohio State University, Columbus, OH, USA,
4 University of Toronto, Toronto, Canada,
5 Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
Objective. To describe strategies employed during handoffs in four settings with high consequences for failure.
Design. Analysis of observational data for evidence of use of 21 handoff strategies.
Setting. NASA Johnson Space Center in Texas, nuclear power generation plants in Canada, a railroad dispatch center in the United States, and an ambulance dispatch center in Toronto.
Main measure. Evidence of 21 handoff strategies from observations and interviews.
Results. Nineteen of 21 strategies were used in at least one domain, on at least an ‘as needed’ basis.
Conclusions. An understanding of how handoffs are conducted in settings with high consequences for failure can jumpstart endeavors to modify handoffs to improve patient safety.
Keywords: coordination, fatigue, grounded theory, handoff, human factors, patient safety, nursing, physician
Address reprint requests to Emily Patterson, Veteran’s Administration Getting at Patient Safety (GAPS) Center, 210 Baker Systems, 1971 Neil Avenue, Columbus, OH 43210, USA. E-mail: patterson.150{at}osu.edu
Accepted for publication November 19, 2003.
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