Structuring flexibility: the potential good, bad and ugly in standardisation of handovers

The findings from the paper in this issue add to the growing empirical evidence that patient handovers in all healthcare settings are highly variable in content and process, and the authors recommend reducing this variability by standardising sign-out protocols.

Abstract

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 al 2 ( 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: 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: