[tghw]

I think it's probably more about protocol. One example is that some departments would hand off in alphabetical order by patient name. Seems logical, but if Ms. Abraham is doing just fine, but Mr. Zimmerman is in critical condition, well, you can see the flaw. They found that doing handoffs in order of severity helped decrease error rates.

The other issue is interruptions. Hospitals are busy places, and sometimes someone needs to get in and get some information from one of the doctors doing the handoff, causing a legitimate interruption. As we know, even a few seconds can derail your whole train of thought. It's definitely still an open problem.