Signing Out PatientsSigning Out PatientsMyra Lalas Pitt

Consequences of Inadequate Sign-Consequences of Inadequate Sign-out for Patient Careout for Patient Care

Horwitz, L et al. from Archives of Internal Medicine 2008

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: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.

Verified sign-out inadequacies by reviewing each corresponding oral and written sign-out.

ResultsSign-out sessions (N = 88) included 503 patient

sign-outs. Interns of 84 of 88 sign-out sessions (95%) were

interviewed 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.

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.

ConclusionOmission of key information during sign-out can

have important adverse consequences for patients and health care providers.

Communication failures in patient sign-Communication failures in patient sign-out and suggestions for improvement: out and suggestions for improvement: a critical incident analysisa critical incident analysis

Arora, V. Qual Saf Health Care. 2005Background

The transfer of care for hospitalized patients between inpatient physicians is routinely mediated through written and verbal communication or "sign-out". This study aims to describe how communication failures during this process can lead to patient harm.

MethodsIn interviews employing critical incident technique,

interns described (1) any adverse events or near misses due to suboptimal preceding patient sign-out; (2) the worst event due to suboptimal sign-out in which they were involved; and (3) suggestions to improve sign-out.

All data were analyzed and categorized using the constant comparative method with independent review by three researchers.

Box 1 Intern interview questions regardingsign-outQuestion designed to elicit information about

adverse events and near misses: ‘‘Was there anything bad thathappened or

almost happened last night because the(VERBAL/WRITTEN) sign-out wasn’t as good as it could have been?’’*

Question designed to elicit information about worst event experienced in past year:

‘‘Can you tell me the single most severe adverse event that you were involved in over the last year that resulted from a deficient sign-out?’’

Question designed to elicit information about ideas for improvement: ‘‘Regardless of whether anything went wrong or almost went wrong and thinking about what should be included in a sign-out, is there anything

about the (VERBAL/WRITTEN) sign-out that you received that you think should have been better?’’*

*Question repeated for verbal and written sign-out.

ResultsTwenty six interns caring for 82 patients wereinterviewed after receiving sign-out from anotherintern.

Twenty five discrete incidents, all the result ofcommunication failures during the preceding patientsign-out, and 21 worst events were described.

Inter-rater agreement for categorization was high (k 0.78– 1.00).

Omitted content (such as medications, active problems,pending tests) or failure-prone communicationprocesses (such as lack of face-to-face discussion)emerged as major categories of failed communication.

In nearly all cases these failures led to uncertainty duringdecisions on patient care.

Table 1 Categories of communication failure in sign-out from preceding shift

Category Subcategory

Content Omissions Active Medical ProblemsMeds or treatmentsLabs or consults

Failure- prone communication processes

Double sign outNo face to face communicationIllegible or unclear notes

Attempt to solve uncertainty Unnecessary or repeat workSolicit info from others

ConclusionCommunication failures during sign-out often lead

to uncertainty in decisions on patient care.

These may result in inefficient or suboptimal care leading to patient harm.

Table 6 Taxonomy of sign-out quality

Poor sign-outContent omissionsMedications or

treatmentsTests or consultsMedical problemsBaseline statusCode statusRationale of primary

team

Effective sign-outWritten sign-outCode statusAnticipated

problemsBaseline

examinationPending test or

consultsLegible

Failure-prone Communication

processes*Lack of face-to-facecommunication*Double sign-out*illegible handwriting

Verbal sign out*Anticipate*Pertinent*Face-to-face*Thorough

From Joint Commission OnlineFrom Joint Commission Online

Miscommunication between caregivers when responsibility for patients is transferred or handed-off plays a role in an estimated 80 percent of serious preventable adverse events.

Recognizing this as a critical patient safety issue, a group of 10 leading U.S. hospitals and health care systems teamed up with the Joint Commission Center for Transforming Healthcare in August 2009 to use Robust Process Improvement™ (RPI) methods – including Lean Six Sigma and change management – to find the causes of and put a stop to these dangerous and potentially deadly breakdowns in patient care.

The participating hospitals found that, on average, more than 37 percent of the time hand-offs were defective and did not allow caregivers receiving responsibility to safely care for the patient.

Additionally, 21 percent of the time those initiating the care transition were dissatisfied with the quality of the hand-off.

By using solutions targeted to the specific causes of an inadequate hand-off, participating organizations that had fully implemented solutions achieved an average 52 percent reduction in defective hand-offs.

PATIENT NAME, AGE/SEX, MRN,DATE OF ADM

DIAGNOSIS EVENTS RESPIRATORYFEN/GIDIET

MEDICATIONS LABS/ RADIO TO DO

Mora Dawin16y/o M89124707/25/11TRAUMA

L hemothorax, s/p CT placementL lung contusionMultiple stab wounds 2 cm, superf (9 paraspinal, 3 R buttock, ! Lbuttock, 1 L post thigh, 2 R hand)

Chest tube was removed

RAISRegularSL

Percocet 2 tabs po q6Morphine q4 PRNBacitracin tid

CMP: wnlCBC: Hb 14.9 12.8 Platelets 240 287Coags: wnlARh-VBG:wnlCT brain:wnlCT abd: no injuryCT chest: L apical pneumothorx,

CXR in AM ?

Jackson, Chantaysia19 yo F8913837/26/11

L pyelonephritisL nephrolithiasis

T: 100.8Nausea

RARegular dietIVF: d5 ½ NS + 20 KCl 50ml/h (1/2: M)

Ceftriaxone 2 gr IV q day 1/14Azythro 1 gr x 1Ketorolac 30 mg IV q 6 h RTCMorphine 2 mg IV q 4 h PRN painTylenol 650 mg q 4 h pain, feverZofran 4 mg IV q 8 h PRN nausea

Ua: WBC: > 180, RBC: 7, bact: few138/3.2 104/26 10 0.9 6.9/4 14/19 89/1.715.3>13.9/39.6<224CT abd: 6mm nonobstructing L renal calculus, L renal cyst, immflamatory changes of the bladder wall

I and O strain the urinePain managementF/U tomorrow with urology

INPATIENT SIGN OUT: 07/26/11 pm Xray x4203 Micro x4146 Chemistry x6154 Hematology x4159 Total Care 933-9900 Rite Aid 220-2226 Fuller 292-4244

ReferencesReferences

Arora, V. et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care

2005;14:401–407. doi: 10.1136/qshc.2005.015107Horwitz, L. et al. Consequences of Inadequate Sign-out for Patient Care. Arch

Intern Med. 2008;168(16):1755-1760.