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  • Rebecca Bugas


My daughter recently dislocated her kneecap during PE and the high school called frantically to let me know she was on her way to the emergency room. When I arrived at the hospital, my daughter’s knee had been popped back in place, but she was still in terrible pain, and the swelling was setting in. When the attending doctor came around to introduce himself, I asked if they had given her anything for the pain before I arrived. They had not (really???), so I asked for Advil and some ice or anti-inflammatory to help with the swelling since she could barely move and was still crying from the trauma. That was at 1pm.

After waiting patiently for the Advil (something usually in my purse) for 45 minutes, I noticed some fresh and rested faces arriving at the ER. I asked someone else to check on the meds we requested, and they said the order had been placed by the attending doctor and should be up soon. Shortly I asked again, only to be told there was a shift change at 2 pm, that our doctor had left for the day and the new doctor would look into my request. By 3 pm with no help in sight, I lost it! After trying to comfort my daughter for two hours with mere words and a Dixie cup of water, I was enraged. I raised my voice over the painful tears of my daughter until a nurse came over with three tablets and apologized that “no request for pain medication was made when the doctors made the handoff.” I was grateful for the dose but furious about the wait, and I could not help but think about how often this happens right before, during or right after a shift change in other emergency rooms? And if information is not being passed on during shift changes in a highly intense, potentially life-threatening setting like an emergency room, then likely the same thing is happening in other places that require 24 hours service, like fire station and police dispatch, manufacturing plants, airports, surveillance/security, crisis hotlines, etc. Imagine the dangers to workers and the public if the shift handoff misses something at a nuclear power plant or water treatment plant? Alternatively, what if my daughter’s injury was much worse than just a painful dislocation?

It so happens that I work at Coleman Consulting Group, a consulting firm that specializes in helping companies find and implement the right shift schedules. Shift changes and effective employee handoffs are critical to most schedules. So, I asked the question...does this happen often, or was mine just an isolated incident? The answer is scary.

It turns out that many organizations have shift changes that are not very well planned, and things do get missed. More often than not, there is a drop in productivity at the start of each new shift… 20-30% losses in the first hour are not uncommon. More frightening is the increase in accidents that first hour that can lead to personal injury and equipment failures. Solving the problem requires finding the right medium and the correct methodology that works for that organization. It is important to have processes to ensure that the shift change procedure is being adhered to and periodically reviewed. With a little effort and leadership, the process can be resolved so that items are not dropped, and issues that come up just before or during the change are dealt with effectively.

I wish our local hospital had hired Coleman Consulting Group!

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