The need for 24-hour emergency care requires emergency department (ED) staff to work in shifts. Shift changes have long been viewed as risky times, for failures in the transfer of information, authority, or responsibility care can result in adverse events.
We observed shift transitions in the ED as part of a study on safety in emergency care. We found that, in addition to being an expected point of failure, transitions were also, unexpectedly, associated with recovery from failure. We report two illustrative case studies, and examine implications for strategies aimed at reducing the number of and volume of transitions.
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