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Advancing the next generation of handover research and practice with cognitive load theory
  1. John Q Young1,
  2. Robert M Wachter2,
  3. Olle ten Cate3,
  4. Patricia S O'Sullivan2,
  5. David M Irby2
  1. 1Department of Psychiatry, Hofstra North Shore-LIJ School of Medicine, New York, New York, USA
  2. 2Department of Medicine, UCSF School of Medicine, San Francisco, California, USA
  3. 3Center for Research & Development of Education, University Medical Center Utrecht, Utrecht, The Netherlands
  1. Correspondence to Dr John Q Young, Department of Psychiatry, Hofstra North Shore-LIJ School of Medicine, The Zucker Hillside Hospital, 75-59 263rd Street, Kaufman 217A, Glen Oaks, NY 11004, USA; Jyoung9{at}

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Improving patient safety during handovers has become a public health priority.1 Over the past decade, a number of best practices have emerged, which, taken together, represent the first generation of handover interventions. Largely adapted from industries (such as aviation and railroad) in which transition errors have high consequences,2 these first-generation best practices aim to reduce information loss and distortion via structured communication protocols such as face-to-face and written sign-out that use mnemonics and standardised templates, interactive questioning and distraction-free environments.1

These efforts have been fruitful. Interventions that bundle these practices have yielded improvements in educational and clinical outcomes.3 Yet, while these protocols improve safety, handovers still remain an important source of medical error and potential harm to patients. Accordingly, we must now choose how best to identify strategies that improve upon these first-generation interventions. In our view, since handovers are a complex cognitive task, these efforts will require deeper appreciation of human cognitive abilities. The sender and receiver must simultaneously apply and integrate multiple sets of (clinical, communication and systems) knowledge, skills and attitudes into one, time-limited and highly constrained activity.4 As a result, the task demands can easily exceed the information-processing capacity of the clinicians, resulting in impaired learning and performance, errors and harm to the patient.5

To date, handover research and practice has not explicitly applied cognitive theories of learning and information processing to address these cognitive limitations. One such theory, cognitive load theory (CLT), has received increased attention in the medical education literature,5 ,6 and, in a recent study, has been used to unpack the complexity of handovers.7 By highlighting the constraints of human beings’ working memory, we believe that CLT identifies specific cognitive limitations highly relevant to handovers, and can help guide a second generation of handover …

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  • Contributors JQY, RMW, PSO, OtC and DMI all contributed to the planning, conduct and reporting of this article.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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