BMJ Qual Saf 23:528-533 doi:10.1136/bmjqs-2013-002705
  • Viewpoint

The limits of checklists: handoff and narrative thinking

  1. Susan D Moffatt-Bruce2
  1. 1Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, Ohio, USA
  2. 2Department of Surgery, The Ohio State University Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
  1. Correspondence to Professor Brian Hilligoss, College of Public Health, The Ohio State University, 224 Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210-1351, USA; bhilligoss{at}
  • Received 26 November 2013
  • Revised 22 February 2014
  • Accepted 9 March 2014
  • Published Online First 2 April 2014


Concerns about the role of communication failures in adverse events coupled with the success of checklists in addressing safety hazards have engendered a movement to apply structured tools to a wide variety of clinical communication practices. While standardised, structured approaches are appropriate for certain activities, their usefulness diminishes considerably for practices that entail constructing rich understandings of complex situations and the handling of ambiguities and unpredictable variation. Drawing on a prominent social science theory of cognition, this article distinguishes between two radically different modes of human thought, each with its own strengths and weaknesses. The paradigmatic mode organises context-free knowledge into categorical hierarchies that emphasise member-to-category relations in order to apply universal truth conditions. The narrative mode, on the other hand, organises context-sensitive knowledge into temporal plots that emphasise part-to-whole relations in order to develop meaningful, holistic understandings of particular events or identities. Both modes are crucial to human cognition but are appropriate responses for different kinds of tasks and situations. Many communication-intensive practices in which patient cases are communicated, such as handoffs, rely heavily on the narrative mode, yet most interventions assume the paradigmatic mode. Improving the safety and effectiveness of these practices, therefore, necessitates greater attention to narrative thinking.

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