The Current System
In a 2006 survey sent to 324 internal medicine programs, Horwitz and colleagues showed that 55 percent of these programs did not consistently require both a written and an oral sign-out, 34 percent left sign-out to interns alone and 60 percent had no instruction on effective sign-out practices (Arch Int Med. 2006;166:1173-1177). Results also showed that a member of the patient’s primary team was present in the hospital for only 47 percent of the patient’s hospitalization. More recently, a 2011 study in a single institution showed that among 204 observed sign-outs, there were 124 unique versions of the patient handoff (Teach Learn Med. 2011;23:105-111).
Currently, the most common sign-out methods involve the use of spreadsheets or handwritten notes. Wohlauer and colleagues demonstrated that this laborious process required 51 percent of residents to spend one to two hours every day transcribing data and occasionally this resulted in patients being completely missed on rounds (J Surg Res. 2012;172:11-17). With a system that is already subject to staffing stressors due to work hour restrictions, valuable time spent copying results from the EMR is ill advised, inefficient and extremely susceptible to human error.
The overall lack of standardization in the current system results in errors of both commission and omission. In a single-institution study, three recurring problems were identified in the written sign-out: outdated information, a lack of anticipatory guidance and minimal information regarding advanced directives. The authors found that only 50 percent of resident sign-outs had been updated to contain current information, such as accurate medication. In another study, which looked at 6,942 sign-outs, 27 percent of the sheets contained erroneous information, 80 percent of which were omissions. The majority of errors persisted beyond the first day and more than half had the potential to be moderately or severely harmful (Teach Learn Med. 2011;23:105-111).