American Association for Clinical Chemistry
Better health through laboratory medicine
January 2011 Clinical Laboratory News: Shift-to-Shift Communication


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LAB SAFETY CONCEPTS

Shift-to-Shift Communication 
What Can Labs Learn from NASA and other Highly Reliable Organizations?

By Erin Grimm, MD 
Resident 
Department of Laboratory Medicine, University of Washington, Seattle

In healthcare, poor communication between shifts can lead to errors with severe consequences for patients. Other organizations, such as nuclear power, air traffic control, spacecraft mission control, and aviation maintenance, also have shift handoffs where failure to communicate can create the potential for highly negative consequences. Experts working with the National Aeronautics and Space Administration and the Department of Veterans Affairs have compiled best practices from the literature and their own work that are directly applicable to the laboratory (see Table).

Best Practices for Shift-change Communication
Pre-implementation Decisions
1 A shift handoff procedure is written, personnel are trained on performing correct handoffs, and shift handoffs are periodically monitored.
2

The handoff checklist meets the following guidelines:

  • It was written and evaluated by workers in the lab during a trial period during which time they could recommend additions and/or deletions to the list.
  • “Required” fields are specified.
  • The checklist has blank fields for workers to describe unusual occurrences.
  • The checklist is electronic and problems are searchable.
Daily Handoff Preparation
3 The incoming lead assesses current status before the handoff.
4 The incoming lead scans historical data before the handoff.
5 The outgoing lead has protected time to write the shift summary before the handoff.
6 Handoffs ( transfer of responsibility) are delayed during critical times.
Handoff/Structure
7 Interruptions are limited during handoff.
8 Workers change their physical location to signify the job they are performing.
9 Handoff is an equal responsibility of both incoming and outgoing worker.
10 All checklist items are addressed in the same order without skipping any sections.
11 The verbal handoff is face-to-face with interactive questioning.
12 The incoming lead receives paperwork on which they can make handwritten annotations during the handoff.
13 Topics are initiated by incoming staff and outgoing staff.
14 Outgoing shift’s stance or contingency plans on emerging problems is taken into account.
15 Read back occurs to verify information was accurately received.
16 If necessary, additional updates from other areas of the lab are obtained.
17 Outgoing lead oversees incoming’s work following update.
Source: Adapted from references 1 and 2.

The following example, which involves the night-to-day shift transition between lead technicians in specimen processing, illustrates how to implement some of these best practices in the lab. Let’s say the day and night lead technologists’ shifts overlap by 1 hour at the shift change. A protocol should define the entire handoff process (best practice 1). When the incoming lead tech arrives, she takes over at the lead bench (8), allowing the outgoing lead tech uninterrupted time to write the shift summary (5). The change of physical location of both leads serves as a visual cue of the change of leadership (8). While the outgoing lead tech finishes the shift summary, the incoming lead tech assesses the current status of the lab (3) and familiarizes herself with the problems that already have been recorded (4).

When the written documentation is finished, the shift handoff occurs. A sub-lead or second in command (preferably someone from the outgoing shift) takes over the lead’s desk and duties (8) to keep the leads from being interrupted during handoff (7). The handoff conversation is structured in the form of a topic checklist that was developed by the lab (2). Each checklist item is addressed systematically—even if there are no issues related to that topic—in a defined order (10). The handoff between leads is a two-way, (9) face-to-face conversation (11) with written/electronic documentation supplementing the verbal handoff (12) and read back (15).

Both the problems and the solutions employed to solve them are addressed (14). The incoming lead tech is an equal participant and asks about other solutions that may have been considered (13). If the problem relates to another section of the laboratory, the incoming lead tech finds the lead tech for that section to get the most current update (16). Following the update, both lead techs work together for whatever time remains in the shift (17). If there is a critical issue at the time of shift handoff such as unexpected downtime of the laboratory information system, the handoff is delayed and both leads focus on the problem (6).

REFERENCES

  1. Parke B and Mishkin A. Best Practices in Shift Handover Communication: Mars Exploration Rover Surface Operations. Proceedings of the International Association for the Advancement of Space Safety Conference sponsored by ESA, NASA, and JAXA, Nice, France, 25–27 October, 2005.
  2. Patterson ES, et al. Handoff strategies in settings with high consequences for failure: lessons for health care operations. International Journal for Quality in Health Care 2004;16: 125–132.
We welcome submissions on communication best practices. Please send them to the editors of Patient Safety Focus, Nancy Sasavage (nsasavage@aacc.org) or Michael Astion (mastion@uw.edu) for possible inclusion in a future issue.


 

Patient Safety Focus Editorial Board

Chair
Michael Astion, MD, PhD
Department of Laboratory Medicine 
University of Washington, Seattle

Members
Peggy A. Ahlin, BS, MT(ASCP) 
Consultant
Salt Lake City, Utah 

Corinne Fantz, PhD
Emory University
Atlanta, Georgia

James S. Hernandez, MD, MS
 
  Mayo Clinic Arizona 
Scottsdale and Phoenix


Brian R. Jackson
ARUP Laboratories
Salt Lake City, Utah

Sponsored by ARUP Laboratories, Inc.
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