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 In a single-institution study, three recurring problems were identified in the written sign-out: outdated information, a lack of anticipatory guidance and minimal information regarding advanced directives.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).
Explore This IssueSeptember 2013
Anticipatory guidance is defined as a prediction about events that may transpire, coupled with a plan about how to address these possibilities. This has become a central tenet of safe handoffs. In a prospective survey study, resident physicians characterized their night on call, the adequacy of the sign-out they received and where they found needed information they had not received during sign-out (Qual Saf Health Care. 2008;17:6-10). One-third indicated that an event had transpired that they were not adequately prepared for by the sign-out, and a retrospective look at these events showed that most could have been anticipated and discussed during sign-out.
Proposed and Studied Interventions
The obvious first step is to classify the information that should be included in a proper sign-out. The answers lie not only in the completeness and accuracy of the information given to the covering physician, but also in the quality and efficiency of the verbal, face-to-face communication. In a study from the University of Iowa, three handoff methods were implemented in succession and individually evaluated during three respective phases (Ochsner J. 2012;12:331-337). During phase I, the overnight physician left handwritten notes for the primary team. Phase II consisted of an electronic-based sign-out, with no face-to-face interaction. In Phase III, the residents were required to do verbal handoffs with optional use of electronic or written notes. In Phase I, the risk of an adverse event was nine times greater than in Phase III, and in Phase II, the risk of an adverse event was 7.4 times greater, compared with Phase III, demonstrating the value of face-to-face communication. What is said during the verbal communication should also be standardized. Thus far, few methods have been rigorously studied, but common themes include identifying patient information, reasons for admission, new events that have occurred, specific tasks to be completed, progress of illness and anticipated events during the shift, along with a plan of action.