Example: a ward where handovers kept failing
A composite illustration.
On a 32-bed medical ward in a UK hospital, errors clustered in the hour after each shift change, and each shift blamed the one before.
The team took one event, a fluid restriction not passed on at the 7 a.m. handover, and each person wrote their account first. The facts: handover took 35 minutes, was interrupted four times on average, and the night shift's notes were on a different sheet from the day shift's. The same kind of miss had happened at least five times in three months.
"Nights don't bother" and "days don't listen" faded once the pattern was on the wall. The team chose one handover sheet and a protected ten minutes without interruptions. Six weeks later, there had been two near-misses, both caught at handover.