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. 2005 Dec;14(6):401–407. doi: 10.1136/qshc.2005.015107

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

V Arora 1, J Johnson 1, D Lovinger 1, H Humphrey 1, D Meltzer 1
PMCID: PMC1744089  PMID: 16326783

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 (κ 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.

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Selected References

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  1. Barenfanger Joan, Sautter Robert L., Lang Diane L., Collins Susan M., Hacek Donna M., Peterson Lance R. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol. 2004 Jun;121(6):801–803. doi: 10.1309/9DYM-6R0T-M830-U95Q. [DOI] [PubMed] [Google Scholar]
  2. Beach Christopher, Croskerry Pat, Shapiro Marc, Center for Safety in Emergency Care Profiles in patient safety: emergency care transitions. Acad Emerg Med. 2003 Apr;10(4):364–367. doi: 10.1111/j.1553-2712.2003.tb01350.x. [DOI] [PubMed] [Google Scholar]
  3. Bomba David T., Prakash Robert. A description of handover processes in an Australian public hospital. Aust Health Rev. 2005 Feb;29(1):68–79. doi: 10.1071/ah050068. [DOI] [PubMed] [Google Scholar]
  4. Chew-Graham Carolyn A., May Carl R., Perry Mark S. Qualitative research and the problem of judgement: lessons from interviewing fellow professionals. Fam Pract. 2002 Jun;19(3):285–289. doi: 10.1093/fampra/19.3.285. [DOI] [PubMed] [Google Scholar]
  5. Clarke Paul, Sproston Kerry, Thomas Roger. An investigation into expectation-led interviewer effects in health surveys. Soc Sci Med. 2003 May;56(10):2221–2228. doi: 10.1016/s0277-9536(02)00238-1. [DOI] [PubMed] [Google Scholar]
  6. Cook R. I., Render M., Woods D. D. Gaps in the continuity of care and progress on patient safety. BMJ. 2000 Mar 18;320(7237):791–794. doi: 10.1136/bmj.320.7237.791. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Ebright Patricia R., Urden Linda, Patterson Emily, Chalko Barbara. Themes surrounding novice nurse near-miss and adverse-event situations. J Nurs Adm. 2004 Nov;34(11):531–538. doi: 10.1097/00005110-200411000-00010. [DOI] [PubMed] [Google Scholar]
  8. Henriksen K., Kaplan H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care. 2003 Dec;12 (Suppl 2):ii46–ii50. doi: 10.1136/qhc.12.suppl_2.ii46. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Holden J. D. Hawthorne effects and research into professional practice. J Eval Clin Pract. 2001 Feb;7(1):65–70. doi: 10.1046/j.1365-2753.2001.00280.x. [DOI] [PubMed] [Google Scholar]
  10. Kerr Micky P. A qualitative study of shift handover practice and function from a socio-technical perspective. J Adv Nurs. 2002 Jan;37(2):125–134. doi: 10.1046/j.1365-2648.2002.02066.x. [DOI] [PubMed] [Google Scholar]
  11. Kilpatrick E. S., Holding S. Use of computer terminals on wards to access emergency test results: a retrospective audit. BMJ. 2001 May 5;322(7294):1101–1103. doi: 10.1136/bmj.322.7294.1101. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Lally S. An investigation into the functions of nurses' communication at the inter-shift handover. J Nurs Manag. 1999 Jan;7(1):29–36. doi: 10.1046/j.1365-2834.1999.00095.x. [DOI] [PubMed] [Google Scholar]
  13. Leonard M., Graham S., Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004 Oct;13 (Suppl 1):i85–i90. doi: 10.1136/qshc.2004.010033. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Lingard L., Espin S., Whyte S., Regehr G., Baker G. R., Reznick R., Bohnen J., Orser B., Doran D., Grober E. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004 Oct;13(5):330–334. doi: 10.1136/qshc.2003.008425. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. McDonald Clement J., Overhage J. Marc, Mamlin Burke W., Dexter Paul D., Tierney William M. Physicians, information technology, and health care systems: a journey, not a destination. J Am Med Inform Assoc. 2004 Mar-Apr;11(2):121–124. doi: 10.1197/jamia.M1488. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Mukherjee Siddhartha. A precarious exchange. N Engl J Med. 2004 Oct 28;351(18):1822–1824. doi: 10.1056/NEJMp048085. [DOI] [PubMed] [Google Scholar]
  17. Patterson Emily S., Roth Emilie M., Woods David D., Chow Renée, Gomes José Orlando. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004 Apr;16(2):125–132. doi: 10.1093/intqhc/mzh026. [DOI] [PubMed] [Google Scholar]
  18. Petersen L. A., Brennan T. A., O'Neil A. C., Cook E. F., Lee T. H. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994 Dec 1;121(11):866–872. doi: 10.7326/0003-4819-121-11-199412010-00008. [DOI] [PubMed] [Google Scholar]
  19. Petersen L. A., Orav E. J., Teich J. M., O'Neil A. C., Brennan T. A. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998 Feb;24(2):77–87. doi: 10.1016/s1070-3241(16)30363-7. [DOI] [PubMed] [Google Scholar]
  20. Roughton V. J., Severs M. P. The junior doctor handover: current practices and future expectations. J R Coll Physicians Lond. 1996 May-Jun;30(3):213–214. [PMC free article] [PubMed] [Google Scholar]
  21. Sherlock C. The patient handover: a study of its form, function and efficiency. Nurs Stand. 1995 Sep 20;9(52):33–36. doi: 10.7748/ns.9.52.33.s34. [DOI] [PubMed] [Google Scholar]
  22. Sutcliffe Kathleen M., Lewton Elizabeth, Rosenthal Marilynn M. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004 Feb;79(2):186–194. doi: 10.1097/00001888-200402000-00019. [DOI] [PubMed] [Google Scholar]
  23. Thakore S., Morrison W. A survey of the perceived quality of patient handover by ambulance staff in the resuscitation room. Emerg Med J. 2001 Jul;18(4):293–296. doi: 10.1136/emj.18.4.293. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Van Eaton Erik G., Horvath Karen D., Lober William B., Rossini Anthony J., Pellegrini Carlos A. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg. 2005 Apr;200(4):538–545. doi: 10.1016/j.jamcollsurg.2004.11.009. [DOI] [PubMed] [Google Scholar]
  25. Volpp Kevin G. M., Grande David. Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003 Feb 27;348(9):851–855. doi: 10.1056/NEJMsb021667. [DOI] [PubMed] [Google Scholar]
  26. Wilson R. M., Runciman W. B., Gibberd R. W., Harrison B. T., Newby L., Hamilton J. D. The Quality in Australian Health Care Study. Med J Aust. 1995 Nov 6;163(9):458–471. doi: 10.5694/j.1326-5377.1995.tb124691.x. [DOI] [PubMed] [Google Scholar]

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