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EDUCATION AND TRAINING |
1 Department of Medicine, University of Chicago, Chicago, IL, USA
2 American Board of Medical Specialties, Evanston, IL, USA
3 Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
4 Department of Economics and Harris School of Public Policy, University of Chicago, Chicago, IL, USA
Correspondence to:
Dr V Arora
University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637, USA; varora{at}medicine.bsd.uchicago.edu
ABSTRACT
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.
Methods: In interviews employing critical incident technique, first year resident physicians (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.
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 (
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. Uncertainty may result in inefficient or suboptimal care such as repeat or unnecessary tests. Interns desired thorough but relevant face-to-face verbal sign-outs that reviewed anticipated issues. They preferred legible, accurate, updated, written sign-out sheets that included standard patient content such as code status or active and anticipated medical problems.
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.
Keywords: communication failure; doctor-doctor communication; critical incident analysis; patient sign-out; patient safety
Relevant Article
Qual. Saf. Health Care 2005 14: 393.
This article has been cited by other articles:
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  L. I. Horwitz, T. Moin, H. M. Krumholz, L. Wang, and E. H. Bradley Consequences of Inadequate Sign-out for Patient Care Arch Intern Med, September 8, 2008; 168(16): 1755 - 1760. [Abstract] [Full Text] [PDF]
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 W. Dunn and J. G. Murphy The Patient Handoff: Medicine's Formula One Moment Chest, July 1, 2008; 134(1): 9 - 12. [Full Text] [PDF]
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V. Arora and D. Meltzer Effect of ACGME Duty Hours on Attending Physician Teaching and Satisfaction Arch Intern Med, June 9, 2008; 168(11): 1226 - 1228. [Full Text] [PDF]
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J. M. Farnan, H. J. Humphrey, and V. Arora Supervision: A 2-Way Street Arch Intern Med, May 26, 2008; 168(10): 1117 - 1117. [Full Text] [PDF]
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 J M Farnan, J K Johnson, D O Meltzer, H J Humphrey, and V M Arora Resident uncertainty in clinical decision making and impact on patient care: a qualitative study Qual. Saf. Health Care, April 1, 2008; 17(2): 122 - 126. [Abstract] [Full Text] [PDF]
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D P Stevens Handovers and Debussy Qual. Saf. Health Care, February 1, 2008; 17(1): 2 - 3. [Full Text] [PDF]
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S M Borowitz, L A Waggoner-Fountain, E J Bass, and R M Sledd Adequacy of information transferred at resident sign-out (inhospital handover of care): a prospective survey Qual. Saf. Health Care, February 1, 2008; 17(1): 6 - 10. [Abstract] [Full Text] [PDF]
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V M Arora, J K Johnson, D O Meltzer, and H J Humphrey A theoretical framework and competency-based approach to improving handoffs Qual. Saf. Health Care, February 1, 2008; 17(1): 11 - 14. [Abstract] [Full Text] [PDF]
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H. Singh, E. J. Thomas, L. A. Petersen, and D. M. Studdert Medical Errors Involving Trainees: A Study of Closed Malpractice Claims From 5 Insurers Arch Intern Med, October 22, 2007; 167(19): 2030 - 2036. [Abstract] [Full Text] [PDF]
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 L. I. Horwitz, M. Kosiborod, Z. Lin, and H. M. Krumholz Changes in Outcomes for Internal Medicine Inpatients after Work-Hour Regulations Ann Intern Med, July 17, 2007; 147(2): 97 - 103. [Abstract] [Full Text] [PDF]
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K. G. Shojania, K. E. Fletcher, and S. Saint Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection. Ann Intern Med, October 17, 2006; 145(8): 592 - 598. [Abstract] [Full Text] [PDF]
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L. I. Horwitz, H. M. Krumholz, M. L. Green, and S. J. Huot Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med, June 12, 2006; 166(11): 1173 - 1177. [Abstract] [Full Text] [PDF]
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V. Arora, C. Dunphy, V. Y. Chang, F. Ahmad, H. J. Humphrey, and D. Meltzer The effects of on-duty napping on intern sleep time and fatigue. Ann Intern Med, June 6, 2006; 144(11): 792 - 798. [Abstract] [Full Text] [PDF]
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D P Stevens Turn up the heat on health professions education. Qual. Saf. Health Care, April 1, 2006; 15(2): 78 - 79. [Full Text] [PDF]
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I Philibert and D C Leach Re-framing continuity of care for this century Qual. Saf. Health Care, December 1, 2005; 14(6): 394 - 396. [Full Text] [PDF]
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