作者: Robert L. Wears , Shawna J. Perry , Marc Shapiro , Christopher Beach , Pat Croskerry
DOI: 10.1177/154193120304701209
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摘要: The need for 24-hour emergency care requires department (ED) staff to work in shifts. Shift changes have long been viewed as risky times, failures the transfer of information, authority, or responsibility can result adverse events.We observed shift transitions ED part a study on safety care. We found that, addition being an expected point failure, were also, unexpectedly, associated with recovery from failure. report two illustrative case studies, and examine implications strategies aimed at reducing number volume transitions.