Numerous quality improvement projects on patient handoffs have been conducted in the last decade. Most of these projects intervene with a prescriptive model for conducting handoffs. This exploratory pilot study re-analyzed an existing repository of de-identified field notes on handoffs to answer the question: How do healthcare personnel react when deviations from prescriptive handoff practices are detected? We discuss how these findings suggest that prescriptive interventions may fail without having clear expectations for peer-to-peer positive feedback for appropriate deviations during contingencies and negative feedback when deviations increase risks to what is judged to be an unacceptable level.
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