Missed Medication: a Next‑in‑Line Handoff on the Medical Ward
A real-world example of Next-in-line effect in action
Context
A busy medical ward used an oral, round‑robin handover each morning where nurses and junior doctors reported patient updates aloud in sequence. The team routinely rotated speakers, and clinical updates were often interleaved with administrative notes and immediate task planning.
Situation
During one handover, a registrar announced a late change to a patient’s anticoagulation dose immediately before a junior nurse who was next to speak. The nurse was mentally preparing what she intended to report about her assigned patients while listening to the registrar’s update.
The bias in action
Because the nurse was rehearsing her own report, she failed to encode the registrar’s dose change into memory — a classic next‑in‑line effect where attention is focused inward on upcoming performance rather than on incoming information. When it was her turn she gave the expected update but did not repeat or act on the new anticoagulation instruction. The dose change, mentioned just before her turn, was not retained despite being clinically relevant to one of her patients.
Outcome
The patient received the previously scheduled dose instead of the revised dose; this resulted in a minor bleeding complication that required monitoring and led to an extra day of observation. The incident triggered an internal safety review and a formal incident report.