Sign-out inadequacies during transfers really do endanger patients

December 1, 2008

Poor communication among house staff during transfer of patient responsibility is clearly connected to adverse consequences several hours later.

Poor communication among house staff during transfer of patient responsibility is clearly connected to adverse consequences several hours later-sometimes for patients and sometimes for interns-according to a study in the Archives of Internal Medicine (9/2008). The study of sign-out sessions among internal medicine residents rotating on general medicine units at Yale-New Haven (CT) Hospital was based on 88 sign-out sessions involving 503 sign-outs.

Sign-out inadequacies generally were related to omitted information that resulted in treatment delays, inefficiencies, or duplication of effort. Six types of omissions accounted for most sign-out related problems:

Omission of current clinical condition made it difficult for the interns to prioritize a patient's care or identify clinical deterioration.

Omission of anticipatory guidance for likely overnight events resulted in some of the most serious problems. One patient who had seizures repeatedly during her hospitalization, for instance, was signed out without any guidance about effective treatment for her seizures.

Omission of an assignment, such as to follow up the results of a test performed earlier, could result in abnormal results being overlooked.

Omission of instructions about how to complete a task could force interns to improvise. One intern was told to discontinue treatment with an insulin drip without being told what subcutaneous insulin regimen to use afterward, while another was instructed to send a patient for a vascular study without being told what to do about the patient's anticoagulation.

Omission of a rationale for the assigned task left interns unable to deal efficiently or effectively with unanticipated sequelae because they did not fully understand why the task was assigned in the first place.

The study's authors noted that standardizing the sign-out format by using templates prompts comprehensive sign-out content and has been shown to reduce errors.