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Arch Intern Med. 2008 Sep 8;168(16):1755-60. doi: 10.1001/archinte.168.16.1755.

Consequences of inadequate sign-out for patient care.

Author information

1
Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 789 Howard Ave, New Haven, Connecticut 06519, USA. horwitz@yale.edu

Abstract

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.

PMID:
18779462
DOI:
10.1001/archinte.168.16.1755
[Indexed for MEDLINE]

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