Latest / The New Physician: Today’s Difficult Problem
Where Good People Create Bad Systems
Some of the most dangerous failures in organizations happen not within departments, but between them.
Medicine learned this with structured handoffs such as SBAR. Aviation learned it with explicit, acknowledged transfers of responsibility. In both cases, the lesson is the same: sending information is not the same as transferring ownership.
This episode introduces a simple four-question handoff test:
What crosses the boundary? Who owns it before the handoff? Who explicitly accepts it afterward? How do we know the transfer worked?
Read-backs, checklists, reconciliation, and observable tests can…
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