BACKGROUND: In case reports, transfers in the care of patients among health care providers have been linked to adverse events. However, little is known about the nature and frequency of these transfer-related problems. METHODS: We conducted a prospective audiotape study of 12 days of "sign-out" of clinical information among 8 internal medicine house-staff teams. Each day, postcall and night-float interns were asked to identify any sign-out-related problems occurring during the coverage period and to identify the associated sign-out inadequacies. We verified reported sign-out inadequacies by reviewing each corresponding oral and written sign-out. We then developed a taxonomy of types of errors and their consequences through an iterative coding process. RESULTS: Sign-out sessions (N = 88) included 503 patient sign-outs. A total of 184 patients were signed out twice in the same night. Thus, there were 319 unique patient-days in the data set. We interviewed intern recipients of 84 of 88 sign-out sessions (95%) about sign-out-related problems. Postcall interns identified 24 sign-out-related problems for which we could verify sign-out inadequacies. Five patients suffered delays in diagnosis or treatment, resulting in 1 intensive care unit transfer, and 4 patients had near misses. In addition, house staff experienced 15 inefficiencies or redundancies in work. Sign-outs omitted key information, such as the patient's clinical condition, recent or scheduled events, tasks to complete, anticipatory guidance, and a specific plan of action and rationale for assigned tasks. CONCLUSION: Omission of key information during sign-out can have important adverse consequences for patients and health care providers.
BACKGROUND: In case reports, transfers in the care of patients among health care providers have been linked to adverse events. However, little is known about the nature and frequency of these transfer-related problems. METHODS: We conducted a prospective audiotape study of 12 days of "sign-out" of clinical information among 8 internal medicine house-staff teams. Each day, postcall and night-float interns were asked to identify any sign-out-related problems occurring during the coverage period and to identify the associated sign-out inadequacies. We verified reported sign-out inadequacies by reviewing each corresponding oral and written sign-out. We then developed a taxonomy of types of errors and their consequences through an iterative coding process. RESULTS: Sign-out sessions (N = 88) included 503 patient sign-outs. A total of 184 patients were signed out twice in the same night. Thus, there were 319 unique patient-days in the data set. We interviewed intern recipients of 84 of 88 sign-out sessions (95%) about sign-out-related problems. Postcall interns identified 24 sign-out-related problems for which we could verify sign-out inadequacies. Five patients suffered delays in diagnosis or treatment, resulting in 1 intensive care unit transfer, and 4 patients had near misses. In addition, house staff experienced 15 inefficiencies or redundancies in work. Sign-outs omitted key information, such as the patient's clinical condition, recent or scheduled events, tasks to complete, anticipatory guidance, and a specific plan of action and rationale for assigned tasks. CONCLUSION: Omission of key information during sign-out can have important adverse consequences for patients and health care providers.
Authors: Mark E Barry; Beth R Hochman; Meghan B Lane-Fall; Denise Zappile; Daniel N Holena; Brian P Smith; Lewis J Kaplan; Ann Huffenberger; Patrick M Reilly; Jose L Pascual Journal: Acad Med Date: 2017-07 Impact factor: 6.893
Authors: Nicholas A Rattray; Mindy E Flanagan; Laura G Militello; Paul Barach; Zamal Franks; Patricia Ebright; Shakaib U Rehman; Howard S Gordon; Richard M Frankel Journal: J Gen Intern Med Date: 2018-12-10 Impact factor: 5.128
Authors: Jeanne M Farnan; J A M Paro; R M Rodriguez; S T Reddy; L I Horwitz; J K Johnson; V M Arora Journal: J Gen Intern Med Date: 2010-02 Impact factor: 5.128