Table 3 Observable events during Hand-it-on and examples of relations to clinical practice

Sequence errors, where an object is passed to the wrong person.

• Omitting a step in an algorithm, such as the ABCD approach.

• Lacking a piece of information during a handover situation.

Dropping objects.

• A technical error in the procedure, for example, perforating a vessel while placing an intravenous access.

One participant holds more than one object at a time.

• A leader who tries to coordinate the tasks in the team while ventilating the patient manually.

• A nurse who receives more than one request at the same time.

Little or no verbal communication, for example, not using names.

• Not addressing a member in a trauma team directly but asking someone, so that the message does not reach the intended person.

Participants throw objects without caring whether another person can catch the object.

• Asking an orderly to fetch something from a different room and ignoring the objection from that person that it is not part of the agreed job description. This creates a dilemma arising from the conflicting conditions of the official job regulations and the current, pressing, social environment.

Different participants assign different relative importance to the objects in the simulation (and are unaware of doing so).

• Different priorities in the treatment based on the highly specialized views of those involved, representing different professions and disciplines.

Different participants have different understandings of the speed vs. accuracy trade-off across the objects [51]: Some try to hand on things quickly; others try not to make any errors.

• Handover situations between colleagues where the attempt to use the Situation, Background, Assessment, Recommendation (SBAR) [52] structure is interrupted by the request to concentrate on the key issues only.

Questioning the task and the priorities with—often unclear—questions to “senior management” and continuing without getting clear answers.

• Change processes in a department where the goals of the change and the manner of its implementation are not communicated clearly.

Jokes and “play” in the beginning as the simulation is still slow.

• Trying different approaches in treating the patient while the workload is low.

• Being tricked into a lower level of alertness while the patient’s problem seems easy, possibly resulting in an “everything OK fixation error” [20].

Systematic variation of passing on the objects, for example, trying different hand positions to make it easier to receive the objects.

• Systematically varying the way that a new intravenous needle is manipulated to get a feeling of its characteristics.

Helping each other by correcting errors, for example, by pointing out that another person should receive an object.

• Mentioning to a leader that the medication he/she is about to request has already been administered.

Deliberately making it difficult for each other to receive the object.

• Not mentioning that a piece of equipment requested has arrived, because the colleague asked in a harsh tone for it.

Throwing objects out of the circle.

• Ignoring the request by a younger colleague to get some feedback about his/her performance in a certain procedure.

Assigning certain people to handle the “unexpected events”

• Establishing Medical Emergency Teams in an organization.

Establishing some kind of rhythm that helps in the pacing of the exercise, for example, memorizing which object is received from which person and to whom it needs to be passed.

• Establishing a habitual information flow pattern in departments, whether by written or oral agreement.