The Shift Change

Patient mortality spikes during hospital shift changes.

Not because nurses are tired.

Because context doesn't survive handoffs.

Studies show 50-80% of serious adverse events in hospitals are caused by communication failures during care transitions.

Same patient. Different nurse. Lost information.

The medication order that wasn't passed on. The allergy that got dropped. The declining vital sign that seemed stable to someone who didn't see the trend.

Every handoff degrades context. Every degradation creates risk.

The military knows this. Their studies found U.S. expeditionary care lacks standardized handoff tools. Trauma records from point of injury are often incomplete. Information degrades at every transfer.

This isn't a training problem.

It's a physics problem.

Information has to travel across space. Every time it moves from one person to another, fidelity drops. The question isn't how to handoff better.

It's how to handoff less.

This note explores Spatial Information Degradation, one of four dynamics from The Momentum Engine. Context doesn't survive distance. Design accordingly.