• Hand-off
• complexity
• communication
• emergency department
• human factors

Clinical handoffs are tools aimed at bridging gaps1 that occur during transitions in care, whether across time (eg, shift changes) or across organisational boundaries (eg, the ward to the intensive care unit). They have long been viewed as potential threats to safety2 and are attracting increasing attention for several reasons. First, from a control theory point of view, handoffs are inherently hazardous because having two controllers in a process always raises the possibility of conflict, poor coordination or miscommunication.3 Second, handoffs are often cast among ‘the usual suspects’ in after-the-fact reviews of critical incidents and adverse events,4 ,5 although a few have noted that they have also been sources of recovery from impending danger.6–9 And finally, concerns about fatigue leading to a reduction in work hours present a potential double bind, as decreasing risks from fatigue might be counterbalanced by increasing risks from more frequent handoffs.

Perhaps because …