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Safety Gaps During Patient 'Sign Out'

September 22, 2008
Yale University
Patients may receive poor or delayed care after sign-out -- the transfer of a patient from one doctor to another during a shift change -- researchers report in an Archives of Internal Medicine study.

Patients may receive poor or delayed care after sign-out—the transfer of a patient from one doctor to another during a shift change—Yale School of Medicine researchers report in an Archives of Internal Medicine study.

"We spend a great deal of time in medical school teaching students how to present a patient, but no time at all on sign-out, which occurs more frequently and is high risk," said the study's lead author Leora Horwitz, M.D., assistant professor of internal medicine at Yale School of Medicine. "Closing safety gaps at sign-out could help patients and doctors by reducing duplicative, inefficient care."

Horwitz and co-authors conducted a prospective study of sign-outs involving 319 patients over 12 days. They recorded the oral sign-outs and collected written sign-outs before obtaining reports of subsequent errors. Horwitz said this method allowed them, for the first time, to verify reports of sign-out inadequacies while minimizing bias.

"House staff identified 24 sign-out-related problems, some of which directly affected patients in the form of delayed, inappropriate or redundant care," said Horwitz. "But many of these problems affected doctors, who found themselves duplicating work already done by the primary team or wasting time figuring out what the primary team had already done. These inefficiencies leave doctors less time for direct patient care or rest."

"We were glad to be able to demonstrate, for the first time, the extent of the problem in a systematic fashion," said Horwitz, who also pointed out that these are generally problems that are extremely difficult to identify through chart review or billing data and consequently are often overlooked.

The team found that doctors were often confused about higher-order patient information rather than about factual details. Problems occurred, for example, when doctors did not fully understand the clinical condition of the patient or the rationale behind a test or procedure that had been ordered.

"Sign-out should be about painting a clinical picture of the patient and helping the covering team to act as the primary team would, not about providing long lists of facts that are readily available to the covering team," said Horwitz.

Horwitz maintains that sign-out is a skill that can be taught, assessed and improved, but only if it is a priority in the medical curriculum. The findings have resulted in a new sign-out skills curriculum for Yale medical students and internal medicine house staff.

"We hope that this study will serve as a wake-up call both for training programs and practicing physicians that we need to focus attention on sign-out in order to improve patient safety," said Horwitz.

Other authors on the study included Tannaz Moin, M.D., Harlan Krumholz, M.D., Lillian Wang, M.D., and Elizabeth Bradley.

Citation: Archives of Internal Medicine, Vol. 168, No. 16 (September 2008)

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