Signing Out Patients

1. Signing Out Patients Myra Lalas Pitt

2. Horwitz, L et al. from Archives of Internal Medicine 2008 Background  In case reports, transfers in the care of patientsamong health care providers have been linked to adverse events.However, little is known about the nature and frequency of thesetransfer-related problems. Consequences of Inadequate Sign-out for Patient Care

3. Methods: Prospective audiotape study of12 days of "sign-out" of clinical information among 8 internalmedicine house-staff teams. Each day, postcall and night-floatinterns were asked to identify any sign-out–related problemsoccurring during the coverage period and to identify the associatedsign-out inadequacies. Verified sign-out inadequaciesby reviewing each corresponding oral and written sign-out.

4. Results Sign-out sessions (N = 88) included503 patient sign-outs. Interns of 84 of 88sign-out sessions (95%) were interviewed about sign-out–related problems. Postcall interns identified 24 sign-out–related problemsfor which we could verify sign-out inadequacies. Five patientssuffered delays in diagnosis or treatment, resulting in 1 intensivecare unit transfer, and 4 patients had near misses. House staff experienced 15 inefficiencies or redundancies inwork.

5. Sign-outs omitted key information, such as the patient'sclinical condition, recent or scheduled events, tasks to complete,anticipatory guidance, and a specific plan of action and rationalefor assigned tasks.

6. Conclusion Omission of key information during sign-outcan have important adverse consequences for patients and healthcare providers.

7. Arora, V. Qual Saf Health Care. 2005 • Background 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. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

8. Methods In 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.

10. Box 1 Intern interview questions regarding sign-out Question 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?’’

11. 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.

12. Results Twenty six interns caring for 82 patients were interviewed after receiving sign-out from another intern. Twenty five discrete incidents, all the result of communication failures during the preceding patient sign-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 communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. In nearly all cases these failures led to uncertainty during decisions on patient care.

14. Conclusion Communication 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.

15. Poor sign-out Content omissions • Medications or treatments • Tests or consults • Medical problems • Baseline status • Code status • Rationale of primary team Effective sign-out Written sign-out • Code status • Anticipated problems • Baseline examination • Pending test or consults • Legible Table 6 Taxonomy of sign-out quality

16. Failure-prone Communication processes *Lack of face-to-face communication *Double sign-out *illegible handwriting Verbal sign out *Anticipate *Pertinent *Face-to-face *Thorough

17. 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. From Joint Commission Online

18. 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.

20. 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

21. 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.2005.015107 Horwitz, L. et al. Consequences of Inadequate Sign-out for Patient Care. Arch Intern Med. 2008;168(16):1755-1760. References