Handoff strategies in settings with high consequences for failure: Lessons for health care operations

International Journal for Quality in Health Care

Volumn 16, Issue 2, 2004, Pages 125-132

  Patterson, Emily S ^a,c,f   Roth, Emilie M ^b   Woods, David D ^c   Chow, Renée ^d   Gomes, José Orlando ^e  

^a Veterans Administration Getting at Patient Safety (GAPS) Center   (United States)

^b Roth Cognitive Engineering   (United States)

^c OHIO STATE UNIVERSITY   (United States)

^d UNIVERSITY OF TORONTO   (Canada)

^e FEDERAL UNIVERSITY OF RIO DE JANEIRO   (Brazil)

^f Veteran's Administration GAPS Center   (United States)

Author keywords

Coordination; Fatigue; Grounded theory; Handoff; Human factors; Nursing; Patient safety; Physician

Indexed keywords

AMBULANCE; ARTICLE; CANADA; CLINICAL OBSERVATION; EVIDENCE BASED MEDICINE; HEALTH CARE SYSTEM; INFORMATION SYSTEM; INTERVIEW; NUCLEAR POWER PLANT; PATIENT CARE; PLANNING; PRIORITY JOURNAL; RAILWAY; SAFETY; SPACE FLIGHT; UNITED STATES;

CANADA; HEALTH FACILITIES; INFORMATION DISSEMINATION; ORGANIZATIONAL CASE STUDIES; PRIVATE SECTOR; RISK; SAFETY; UNITED STATES;

EID: 1842832822     PISSN: 13534505     EISSN: None     Source Type: Journal    
DOI: 10.1093/intqhc/mzh026     Document Type: Article

References (20)

1. Cook RI, Woods DD, Miller C. A Tale of Two Stories: Contrasting Views on Patient Safety. National Patient Safety Foundation, April 1998. Chicago, IL: National Patient Safety Foundation: http://www.npsf.org/exec/toc.html Accessed 22 October 2003.
2. Parker J, Gardner G, Wiltshire J. Handover: the collective narrative of nursing practice. Aus J Adv Nurs 1992; 9: 31-37.
3. Liukkonen A. The content of nurses' oral shift reports in homes for elderly people. J Adv Nurs 1993; 18: 1095-1100.
4. Sherlock C. The patient handover: a study of its form, function and efficiency. Nurs Stand 1995; 9: 33-36.
5. Lally S. An investigation into the functions of nurses' communication at the inter-shift handover. J Nurs Manage 1999; 7: 29-36.
6. Wolf Z. Nursing rituals. Can J Nurs Res 1988; 20: 59-69.
7. Patterson ES, Woods DD. Shift changes, updates, and the on-call model in space shuttle mission control. Computer supported cooperative work. J Collab Comput 2001; 10: 317-346.
8. Barden CB, Specht MC, McCarter MD et al. Effects of limited work hours on surgical training. J Am Coll Surg 2002; 195: 531-538.
9. Guerlain S, Smith PJ, Obradovich JH et al. Interactive critiquing as a form of decision support: an empirical evaluation. Hum Factors 1999; 41: 72-89.
10. De Keyser V, Woods DD. Fixation errors: failures to revise situation assessment in dynamic and risky systems. In: Colombo AG, Saiz de Bustamante A (eds). Systems Reliability Assessment. 1990, pp. 231-251.
11. Keyes C. Coordination of care provision: the role of the 'hand-off'. Int J Qual Health Care 2000; 12: 519.
12. Mumaw RJ, Roth EM, Vicente KJ, Burns CM. There is more to monitoring a nuclear power plant than meets the eye. Hum Factors 2000; 42: 36-55.
13. Roth EM, Malsch N, Multer J. Understanding how train dispatchers manage and control trains: results of a cognitive task analysis. US Department of Transportation/Federal Railroad Administration (DOT/FRA/ORD-01/02). Washington, DC: Federal Railroad Administration, 2001: http://www.fra.dot.gov/ Accessed 22 October 2003.
14. Chow R, Vicente KJ. A Field Study of Emergency Ambulance Dispatching: Implications for Decision Support. Proceedings of the 46th Annual Meeting of the Human Factors and Ergonomics Society 2002, pp. 313-317. Human Factors and Ergonomics Society, 2002: http://www.hfes.org/publications/2002proc.html Accessed October 22, 2003.
15. Roth EM, Christian CK, Gustafson M et al. Using field observations as a tool for discovery: analyzing cognitive and collaborative demands in the operating room. Submitted for publication.
16. Strauss AL, Corbin J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage, 1990.
17. Ericsson K, Simon H. Protocol Analysis: Verbal Reports as Data. Cambridge, MA: MIT Press, 1993.
18. Vicente KJ, Roth EM, Mumaw RJ. How do operators monitor a complex, dynamic work domain? The impact of control room technology. Int J Hum Comp Stud 2001; 54: 831-856.
19. Patterson ES, Watts-Perotti J, Woods DD. Voice loops as coordination aids in space shuttle mission control. Computer supported cooperative work. J Collab Comput 1999; 8: 353-371.
20. Schreckenghost D, Thronesbery C, Bonasso P, Kortenkamp D, Martin C. Intelligent control of life support for space missions. IEEE Intell Sys 2002; 17: 24-31.