The Ring That Hid the Last Dose: A Medication Handoff Error
A real-world example of Suffix effect in action
Context
In a busy urban hospital, nurses perform verbal shift handoffs at the nurse station while also monitoring phones, pagers, and monitor alarms. The standard handoff practice relied heavily on spoken lists of patients and pending medication tasks, with limited written backup.
Situation
During evening shift change, the outgoing nurse read aloud a five-item list of time-sensitive medication administrations for her patients. Immediately after finishing the list she answered a ringing phone at the station — the brief phone exchange produced an audible suffix (a short unrelated utterance and tone) before the incoming nurse began documenting tasks.
The bias in action
Because the distracting phone exchange followed directly after the verbal list, the incoming nurse was substantially less likely to recall the last one or two medications on the list. The brief auditory suffix disrupted the short-lived echoic memory trace for the final items, reducing the usual recency advantage. The incoming nurse proceeded to document and prepare the first three items accurately but left out the final dose, believing she had captured the full list.
Outcome
One of the omitted medications (a scheduled analgesic) was not administered on time; the patient experienced increased pain and required intervention, and a medication administration record had to be amended. A review of handoff errors over the next month showed several similar omissions tied to verbal handoffs that were followed immediately by phone interactions.
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