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Structuring flexibility: the potential good, bad and ugly in standardisation of handovers
  1. E S Patterson
  1. E S Patterson, Getting at Patient Safety (GAPS) Center, Veterans Administration, Institute for Ergonomics, Ohio State University, Columbus, Ohio, USA; patterson.150{at}

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Few strategies routinely used during shift change handovers in high-reliability organisations (HROs) are used in healthcare.1 The findings from the paper in this issue by Borowitz et al2 (see page 6) add to the growing empirical evidence that patient handovers in all healthcare settings are highly variable in content and process. Similar to other highly respected healthcare researchers, the authors recommend reducing this variability, in this case by standardising sign-out protocols. However, similar to other human factors researchers, I am concerned about the potential unintended consequences from this well-intentioned approach.

A natural experiment is already underway in the USA to standardise patient handovers. This experiment will likely be shaped by these repeating patterns from human factors research in complex socio-technical settings:

  • all decisions require making trade-offs on competing goals;

  • imposing a simple standard on a complex process does not result in simplicity;

  • local actors must tailor a distant supervisor’s plan to the context;

  • people adapt procedures over time in response to feedback;

  • communication is not a (macrocognitive) function, but rather a means to achieve multiple functions in necessarily distributed work;

  • high-performing teams communicate less and more proactively (more push than pull) than low performing teams.

In the context of handover standardisation for patient care, this natural experiment is predicted to have positive impacts as well as negative, unintended consequences—in other words, the good, the bad, and the ugly.


Communication is required to safely transfer responsibility and authority for patient care during a handover. Standardisation reduces the cost of communication because:

  • the “rules” for interaction …

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